Strategies for Nurse Managers June 2010

CLICK to Email E-mail
CLICK for Print Version Print
CLICK for PDF Version PDF


Combating the nurse shortage

After reading this article, you will be able to:

  • Discuss ways organizations can combat the RN shortage

Market-savvy healthcare organizations have implemented workforce development strategies to address the existing and projected labor shortages. This helps organizations determine where their strategic priorities lie. The recent economic downturn will have lasting effects.

The recession, which officially started in December 2007, has affected the job market. Picture the current state of the nursing shortage as a tsunami. The first thing that happens in a tsunami is that the water on the beach rushes away from the shore.

Nurses are filling current vacant positions en masse. Nurses who had planned to retire, work only part-time, or reduce their hours find they have had to change their plans. They are staying and taking on full-time, rather than part-time, positions (Buerhaus, 2009). 

“As RN spouses lost their jobs (70% of RNs are married) or worried that they might be laid off, many non-working RNs rejoined the workforce” (Buerhaus).

With RN vacancies being filled at an exceptional rate, organizations might have an urge to ease their recruitment and retention efforts. This is exactly the wrong strategy to take. 

As the economy begins to adjust, the tidal wave will hit. The impact of the tsunami wave depends on how quickly the economy recovers.

If the economy recovers quickly, jobs will be rapidly added back to the market. Many nurses who had to come back to work or work more hours to supplement the family income will leave the job market (Buerhaus). Nurses who postponed retirement may stay in the market a little longer than anticipated to rebuild their retirement incomes, but they will also leave (Buerhaus).

What about the new graduates coming out of nursing school? In a down economic climate, employers are able to be more selective when posting positions. 

When employers were faced with a lack of experienced nurses applying for jobs in specialty areas (e.g., emergency room or neonatal ICUs), they had no choice but to take on new graduate nurses (Clavreul, 2009).

If the economy recovers at a slower pace, nurses will not leave the workforce. This means that new graduates will continue to have difficulty finding jobs unless they are willing to be flexible and work in a more generalist role. Whether the economic recovery is fast or slow, it will have long-lasting effects on healthcare organizations.

Organizations cannot afford to simply react to the workforce shortage. Instead, they must take steps to reduce the effects of the shortage on their organization and take an aggressive stance on recruitment and retention strategies. The financial viability of an organization depends on it.

Case in point: The cost to fill an RN position due to turnover is between $82,000 and $88,000 (Jones, 2008). RN vacancy rates have an even greater financial effect on organizations. Costly approaches to filling the void include using agency/traveler temporary nurses, mandatory/voluntary overtime, closing patient units, and/or diverting patients to other facilities (Jones).

Editor’s note: This article is based on information found in the book Nursing Orientation Program Builder: Tools for a Successful New Hire Program. For more information, visit


Buerhaus, P.I. (2009). “The shape of recovery: Economic implications for the nursing workforce.” Nursing Economic$ 27(5): 338–336.

Clavreul, G.M. (2009). “Why nursing school grads have trouble finding jobs.” Retrieved November 3, 2009, from 

Jones, C.B. (2008). “Revisiting nurse turnover costs: Adjusting for inflation.” Journal of Nursing Administration 38(1): 11–18.


Best practice

Colorado hospital evaluates ‘missed opportunities’ in rapid response teams

After reading this article, you will be able to:

  • Identify the training techniques used by SACH to educate staff on rapid response teams

Over the past five years, rapid response teams (RRT) have been brought to the forefront of American hospitals. In 2004, the Institute for Healthcare Improvement (IHI) launched its 100,000 Lives Campaign, of which RRTs were a focal point, and in 2008, The Joint Commission added a National Patient Safety Goal requiring hospitals to have a process to recognize and respond to patients who are deteriorating. Those requirements are now located in standards PC.02.01.19, HR.01.05.03, and PI.01.01.01.

Both of these initiatives sparked interest in RRTs among hospitals, especially at St. Anthony Central Hospital (SACH) in Denver, which began to develop its own RRT in conjunction with the IHI initiative.

However, in 2008, SACH officials began to notice a trend of patients who were meeting the criteria for RRT, but for a variety of reasons, the team was not called.

A subgroup of 17 missed opportunities (including deaths) was identified in the first half of 2008. With the help of simulation training and debriefing interviews, SACH was able to lower that number to nine for the second half of 2008 out of 2,400 trauma-related admissions for the year. That number was cut again for 23 total missed opportunities and no resulting patient deaths out of about 2,400 trauma-related admissions in 2009.

Education and simulation training

In 2008, Pamela Bourg, RN, MS, ANP, CNS, director of trauma services, first noticed a trend developing across the trauma patients at SACH. There were particular instances where patients met the criteria for an RRT, but nurses were not calling a team to follow through.

Bourg teamed up with two colleagues, Julie Benz, RN, MS, clinical nurse specialist, and Melissa Richey, RN, BS, clinical nurse for trauma services, to educate the staff at SACH to be more knowledgeable about when to call the RRT and more comfortable in doing so.

Working with the Wells Center in Colorado, a facility that provides state-of-the-art patient simulation tools, Bourg, Benz, and Richey rented a simulation-training dummy.

“Wells Center supplied us with the simulation mannequins, along with the nurse driver,” says Bourg. “But we were able to use our own nurse educators and advance practice nurses to help facilitate the groups.”

The nurse driver helped run the simulation, but SACH staff wrote the script for the missed opportunity scenarios. During the simulation training, a nurse performed an assessment of a patient. Then, based on what the nurse observed, he or she called an RRT.

“The purpose of the simulation training is to help the nurses recognize the signs and symptoms, identify the patients at greater risk, and then distinguish if they need to call an activation of the RRT,” says Bourg.

The staff members at SACH first participated in the simulation training in July 2008. Between August and December 2008, the women analyzed missed opportunities that took place after the simulation training and saw a drop in the number.

Results not typical from simulation training or education

Bourg’s team discovered that when the nurses appropriately identified a patient in need of an RRT, there were acute changes in the patient’s condition. But when the changes to the patient were not as acute and more subtle, the nurses did not notice them quite as readily.

Even though the number of missed opportunities decreased toward the end of 2008, as 2009 began, Bourg watched the numbers increase, despite staff members having gone through simulation training. “We sat down and knew there were other issues we needed to identify because the numbers were increasing,” she says.

At first, Bourg thought it might have something to do with new graduates working at SACH. But after looking at things more closely, she discovered that other factors contributed to the missed opportunities.

“In addition to the huge changeover we saw at SACH, staff members who had been with us for over two years were failing to activate an RRT,” says Bourg.

In hopes of improving the number of missed opportunities, Bourg and her colleagues went back and began interviewing staff members who failed to activate an RRT. They developed a debriefing tool using a variety of nursing literature to help understand why nurses were failing to activate the RRT.

“We try to make sure that when a missed opportunity presents itself, we contact the nurse within 24 to 48 hours to ask them more about the situation,” says Bourg. 

When a nurse has a missed RRT opportunity, an advance practice nurse conducts a debriefing interview, not the manager. 

During the interview, the nurse is asked questions about what was going on at the time of the missed opportunity, what kind of patient report he or she received from the previous nurse, whether there were competing priorities, and so on.

“We are not trying to assign any blame,” says Bourg. “We are trying to create a culture of safety so people are willing to come forward and give us the information to help make our practice better.” In addition, staff went through simulation training again in July 2009.

More ways to encourage the activation of RRT

IHI faculty member Kathy Duncan says the education SACH provides for nurses is a good way of cutting down on missed opportunities. It is also helpful to take opportunities to encourage staff members and let them know that by calling the RRT, they did the “right thing.”

For example, one facility Duncan worked with had a trophy that rotated between units based on which unit had the most calls for an RRT and the least amount of codes.

“Staff members may work for three months and never call a team, but if they see a graph showing the calls other units have made, or see fellow staff members getting gift cards to coffee shops for calling the most RRT, it reminds them that the rapid response system is still in place and rescuing patients,” says Duncan.

Even if it is not clear what is wrong with the patient, but there are some subtle changes, it’s important to communicate to staff that it is always good to have another set of eyes on the patient, says Duncan.

“If the RRT comes in and assesses the patient occasionally, additional information can be gathered or there can be a quick consult or discussion of opportunities to help the patient,” says Duncan.

This tactic is also beneficial because if for some reason the nurse calls the RRT again, the team will know the patient has had previous issues and may work more quickly to assess and intervene.

Looking to the future of missed opportunities

Bourg says SACH will now use simulation training with staff every quarter, as opposed to once per year. 

“The simulation training has provided the most bang for the buck,” says Bourg. “It has shown staff members to no longer consider the least-case scenario, but to instead look into the worst-case scenario.”

Even though SACH saw a reduction in missed opportunities in 2009, the number was still too high, she says. “In 2010, we look to better our number and eventually get down to zero.”


Adapted from Patient Safety Monitor (Briefings on Patient Safety), April 2010, HCPro, Inc.


Patient safety

Interpreters help overcome linguistic and cultural barriers

After reading this article, you will be able to:

  • Develop a process that addresses non-English speakers
  • Choose a qualified interpreter

Nearly half of U.S. physicians say language and cultural barriers are at least minor obstacles to providing high-quality patient care, according to a study released by the Center for Studying Health System Change, a nonpartisan policy research organization located in Washington, DC.

The study highlights the need for healthcare providers to address non-English-speaking patients, especially as the percentage of non-English speakers rises. 

The latest U.S. census data, collected in 2000, says 47 million residents over the age of five (18% of the total population) speak a language other than English at home. In 1990, 31.8 million residents (14%) reported they did not speak English at home, and in 1980, 23.1 million residents (11%) did the same.

Considering communication is at the heart of what staff members do, staff leaders should treat solving the problem of language and cultural barriers as a top priority.

Such obstacles “can lead to wrong clinical paths and poor outcomes, even disastrous outcomes,” says Barbara Bogomolov, RN, MS, BSN, manager of refugee health and interpreter services at Barnes-Jewish Hospital, a member of BJC HealthCare,in St. Louis.

Use interpreters to bridge communication gaps

Patients rely on staff—such as nurses and case managers—to explain forms such as the Important Message from Medicare, provide instruction on performing post-discharge tasks, and ensure their concerns are met. However, many facilities lack resources to address non-English-speaking patients, says Bria Chakofsky-Lewy, RN, supervisor of Community House Calls/Interpreter Services at Harborview Medical Center in Seattle.

Harborview has used its Community Health Calls program to help bridge linguistic and cultural barriers for 16 years.

Originally established to serve the county’s East African and Cambodian refugees, the program has since expanded to provide services to patients that speak Spanish, Vietnamese, and Somali.

Harborview employs 50 state-certified medical interpreters that speak 26 languages and serve a patient population that speaks 80 languages. Harborview had more than 100,000 interpreter encounters in 2009. 

When Harborview has a patient that speaks a language that is not in its medical interpreters’ repertoire, it gets help from an outside interpreter service agency. Facilities that do not have interpreters on staff should at the very least have access to a strong telephone interpreter service, says Bogomolov. Facilities should never rely on a patient’s family members or a bilingual staff member in another department to provide interpretive services. “There are issues of bias, performance, patient safety, and confidentiality,” she says.

The National Standards on Culturally and Linguistically Appropriate Services (CLAS) do not allow a patient’s family members to interpret medical instructions unless the patient specifically requests that they be allowed to do so. 

For more information on the CLAS standards, visit the U.S. Department of Health and Human Services’ Web site at

Facilities can also take advantage of interpreters as a source of cultural information. “It’s not all about language. We are used to Western-educated patients understanding their rights and obligations to make choices for themselves, but many [patients] come from cultures where that is not normal or appropriate,” Bogomolov says.

Tip: Staff should have a pre-conference with interpreters before they interact with patients. During that time, interpreters will learn what the expectations are for the medical encounter, and they can alert healthcare providers of any cultural barriers that may obstruct those expectations.

Choose an interpreter

Interpreters should have credentials or some other means of displaying competence in both languages. Keep in mind good interpreters don’t necessarily provide word-for-word translations. Sometimes medical terms have no direct translation.

“There is no word in Somali for MRI,” Chakofsky-Lewy says.

Although they do not need to possess a strong clinical competence, interpreters should have enough familiarity with medical terminology to be able to create word pictures that the patient can understand.

To make sure that patients comprehend the information, it is best to ask them to explain what they have been told in their own words, Chakofsky-Lewy says.

Document encounters with non-English speakers

The Joint Commission (formerly JCAHO) is developing hospital accreditation standards that aim to advance effective communication and cultural competence. 

The Joint Commission plans to release those standards this year for use in 2011. In the meantime, it has created a crosswalk between the CLAS standards and existing Joint Commission standards, which is available at

During its regular accreditation, The Joint Commission will review the medical record to evaluate a facility’s ability to facilitate non-English speakers. 

Facilities should develop a process to make sure that they properly document encounters with non-English speakers, Bogomolov says.

When patients are registered or admitted to Barnes- Jewish, they are asked what race and ethnicity they identify with and what language they prefer to use for communicating with healthcare providers. 

Staff enter these data into patients’ permanent records, so the questions are asked only once, and information flows down to the inpatient charts. 

Based on the data, staff can determine whether interpretive services are required to bridge cultural or linguistic barriers.

“There should never be a situation where you cannot communicate with a patient,” Bogomolov says.


Adapted from Case Management Monthly, April 2010, HCPro, Inc.


Transformational leadership

To blog or not to blog: CNO connects with staff nurses

After reading this article, you will be able to:

  • Develop a blog in order to communicate with your CNO

There are a number of methods organizations can use to help demonstrate visibility of their CNO, and with readily available, user-friendly technology all around us, something as simple as blogging can turn into a road of communication between the CNO and the staff. St.Vincent Indianapolis Hospital, for example, turned to the nursing portal on its intranet.

“This is our one-stop shop for nurses,” says Sallie Latty, MA, BSN, RN, MRP coordinator at St.Vincent. “We were looking at ways to meet the needs of a younger generation.” That younger generation would be more tech-savvy and more likely to look for updates through electronic means, such as a blog.

It’s not a small task to reach all of the organization’s nurses, either—there are 2,300 nurses at St.Vincent, 1,500 of those at the bedside.

Although talking leadership into adopting new or different technology options can be a challenge in healthcare settings, this was not the case at St.Vincent. It didn’t take any convincing to get the CNO to participate in a blog.

“Our CNO loved it the minute the idea popped up,” says Latty. “There was no need for encouragement— she was really excited about it.”

Choosing content

The blog’s content started directly.

“The very first blog posted was meant to gain feedback on how the nursing staff wanted our CNO to be visible in the organization,” says Latty. “Did they want [her] to have public forums, tours of their units, shadow nurses—what were their thoughts?”

The hope was to use the blog as a direct communication tool. But the first post received only 19 responses.

“We needed to increase awareness the blog existed,” says Latty. “So we focused our efforts on communication.”

Posts were also used to educate as well as thank staff members. For example, one post talked about the daunting task of implementing the electronic medical record (EMR).

“We recently implemented the EMR, and the last blog talked about that, discussing how there might be bumps in the road and thanking everyone for doing their part,” says Latty.

Technological requirements

Setting up the blog was simple. St.Vincent had the blog up and running in less than one day with the help of the organization’s IT department.

It was so convenient, in fact, that it led to one of the first lessons of creating a blog: Have a communication plan in place.

“One thing we realized—and it’s still a pretty new blog—is that if you don’t keep the posts current, people stop going to the site,” says Latty.

And given how busy every CNO is, finding time to write blog posts on a regular basis can be tough. Although they may not take much time, they do require a good deal of thought.

“In hindsight, because the idea surfaced quickly and there was so much excitement, we didn’t spend much time planning what the process would be, what the purpose would be for the blog,” says Latty.

She suggests spending some time with all the parties involved in conceiving and maintaining the blog to create a plan and goal before implementing it.

“Do that up front,” says Latty. “Two questions we encountered later were: Do people know about it? And what is our plan for keeping it current?”

Staff reaction

The blog had the potential to reach those staff members who can be the most difficult for CNOs to find.

“We felt the blog would be a good way to communicate with staff that might be on the night shift, or weekends only,” says Pat Craig, MSN, MBA, RN, FACHE, an MRP coordinator at St.Vincent. “These are times when leadership isn’t always personally available.”

The CNO also started to receive direct e-mails from staff who did not want to post feedback publicly. However, those who do leave public comments can do so anonymously. “Staff have the option of leaving their name or not,” says Latty.

Concerning public posts, two unexpected developments occurred:

Those who left comments were more often than not middle-aged nurses, not the younger generation St.Vincent expected to see when the blog was first conceived 

Non-nurses discovered the blog and were able to comment as well—and they did

“It’s interesting to have non-nurses responding,” says Latty. In fact, the blog received one suggestion from a member of the security staff on how to improve collaboration between nursing and security that turned out to be worth exploring.

Increased visibility

The CNO traveled the floors, encouraging staff members throughout the implementation process. The blog provided a way for the CNO to reach out to staff to convey her experiences and thank them for their efforts. It also gave the CNO a chance to discuss her experiences and observations after shadowing a nurse.

“One of the things a hospital [on the journey to excellence] has to do is show evidence of visibility of nurse leaders,” says Latty. “You have to demonstrate and describe how you do that at an excellent level.”

The shadowing experiences eventually became part of the blog.

“[The CNO] schedules four-hour blocks of time to work alongside a nurse—it allows her to come into contact with physicians and ancillary staff as well as all of the situations that nurse encounters,” says Craig.

This sort of shadowing gives the CNO an opportunity to see the nurse’s perceptions of the organization, the patient’s perceptions of the nursing staff, and a chance to evaluate the processes being used, Craig says.

The blog is only one example of the CNO’s methods for improving visibility to the staff. “[Our CNO] has a routine article in our Nursing at a Higher Level newsletter,” says Latty.

A presence in every meeting

The CNO attends every meeting she is requested to attend, when possible. “Whether a unit has asked her to be at a staff meeting or other opportunities to encounter staff, she is always willing to change her schedule to do so,” says Latty. Because of shared decision-making, staff nurse participation on many committees has increased, giving staff further opportunity to interact with the CNO and other nursing leaders.

“Our CNO also conducts periodic nursing forums. They’re usually planned around a topic or communication item she wants to get the message out about,” says Craig.

Finally, sometimes visibility can be as simple as being out among the staff.

“Sometimes it’s a small thing that helps with exposure,” says Latty. “Going to the cafeteria might seem like a little thing, but when you do that along with all these other pieces, it helps associates feel like they know who the CNO is, especially in a large organization like St.Vincent.”


Adapted from HCPro’s Advisor to the ANCC Magnet Recognition Program®, April 2010, HCPro, Inc.


Hand hygiene

Improving hand hygiene compliance rates with marketing, accountability, and incentives

After reading this article, you will be able to:

  • Identify proven methods to improve hand hygiene compliance
  • Explain how monetary incentives improved rates at Texas Children’s Hospital

The perennial problem in healthcare facilities around the country usually comes back to a very simple 30-second procedure. 

Ask any infection preventionist (IP) about his or her major focus on hand hygiene compliance and you’ll likely hear a number of strategies, obstacles, or frustrations with getting staff members to comply with hand hygiene best practices. Hand hygiene compliance rates vary from facility to facility, and even from unit to unit. 

There are three main methods for measuring hand hygiene compliance, according to The Joint Commission’s (formerly JCAHO) monograph Measuring Hand Hygiene Adherence: Overcoming the Challenges:

  • Direct observation
  • Measuring product use
  • Conducting surveys

However, measuring compliance is just half the battle for IPs. Improving compliance is another challenge. Part of the Joint Commission’s National Patient Safety Goal NPSG.07.01.01 requires facilities to set goals for improving hand hygiene rates, and it’s a continued focus of Joint Commission surveyors (see the December 2009 Briefings on Infection Control for more info).

Texas Children’s Hospital in Houston and Abington (PA) Memorial Hospital have both improved their compliance rates through a variety of successful strategies, from marketing to monetary compensation.

Using hand hygiene spies

A common method to track hand hygiene compliance and improve rates is the use of hand hygiene “spies” or “secret shoppers.” Both Texas Children’s and Abington Memorial have used spies to kick-start their programs.

When she first started, Collette Hendler, MS, RN, CIC, infection preventionist at Abington Memorial, said she used hospital volunteers and physicians waiting for residency as hand hygiene spies, but soon found she needed more observations than they could provide.

Roughly two years ago, Hendler formed a team of hospital employees whose “regular work