In order for you to develop skills in applying the organizational concepts we are studying to your work to identify problems

The Leader’s Toolkit 1: Case Studies

Job Attitudes: A Crisis in Nursing

Los Rayos del Sol Medical Center is hospital and surgery center located in Florida.* A facility with 500 beds, it has recently partnered with the Mayo Clinic. Los Rayos's is experiencing high turnover. The nurse average turnover rate is 14% for hospitals[endnoteRef:1], while Los Rayos has a turnover rate of 21%. New graduate nurses turnover at a rate of 27% within their first year, with an additional 37% of those new nurses wanting to leave.[endnoteRef:2] At Los Rayos, new nurse turnover is 40%. The hospital spends an average of 13 weeks[endnoteRef:3] to fill a vacant position and thousands of dollars per hire.[endnoteRef:4] Turnover often leaves units understaffed which creates poor patient experiences and lower quality of care. [1: KPMG's 2011 US Hospital Nursing Labor Costs Survey] [2: Kovner, C.T., Brewer, C.S., Fairchild, S., Poormina, S., Kim, H., & Djukic, M. (2007). Newly licensed RN's characteristics, work attitudes, and intentions to work. American Journal of Nursing, 107(9), 58–70.] [3: KPMG's 2011 US Hospital Nursing Labor Costs Survey] [4: Jones, C.B. (2008). Revisiting nurse turnover costs: Adjusting for inflation. Journal of Nursing Administration, 38(1), 11–18.]

Why are the nurses leaving? Los Rayos strives to provide the highest quality in patient care, but it also has to manage costs and comply with government regulations. Thus over the last 10 years Los Rayos has made a number of changes. A summary of those changes are outlined below.

· Ten years ago, Los Rayos changed the staffing model. All units had 2 licensed nurses and a housekeeper. Housekeepers were minimum wage staff that helped the nurses do things like wash linens and stock the nurses' station with basics. These tasks can take a lot of time away from the normal nurses' job duties of doing rounds, required charting, administering doctor's orders, and helping patients. Los Rayos promoted the housekeepers to health techs which were supposed to do more patient care tasks, but most were not equipped with the skills. At the same time, Los Rayos reduced the number of nurses by one. This raised staffing ratios from 12 patients to one nurse to 24 patients to one nurse.

· Eight years ago, the Los Rayos cut the annual employee picnic and Christmas party in order to save costs.

· Five years ago, Los Rayos expanded nurses jobs to engage in activities like cost cutting and quality control. It required nurses to provide 3-5 cost saving ideas per year or they would be negatively evaluated on their performance appraisals.

· Four years ago, the firm put a cap on each position's wage brackets, which resulted in nurses with greater than 12 years of service to not receive raises.

· Three years ago, Los Rayos removed the intake coordinator position from all units except the ER and laboratory. This means that unless a patient is admitted to the hospital in the ER or immediately after laboratory testing, the nurse(s) on the unit have to complete the admission paperwork when the patient is brought to the unit.

· Two years ago, Los Rayos began using tablets to for patients charts and dispensing medicine. To prevent drug theft, medicine carts were equipped with a new security system that requires nurses to scan the patient's hospital bracelet with the tablet, select the medication, and confirm the order before the tablet will send the information to the cart and unlock the needed medicine. The process often causes frustration to both nurse and patient as the tablet would not always stay connected to the med-cart or would have other errors.

· A year ago, Los Rayos began requiring all its nurses to take turns developing, planning, and presenting continuing education courses to reduce training costs. The nurses did not receive any additional compensation for the training they developed, nor were they given any recognition or non-monetary rewards.

· Nurses are required to complete 60 hours of continuing education annually in order to for license renewal. Los Rayos used to pay for the nurses to attend these trainings and hourly wage, however that has been removed as well.

· Six months ago, Los Rayos changed from 8 hour to 12 hour shifts to reduce costs and to allow patients to “be closer to their caretakers.” However, patients from the maternity and geriatrics wards have complained about only seeing nurses at the start and end of shift. Some employees like 12 hours shifts; however, most employees agree these shifts are exhausting and the nurses often state they don't have the time and energy to "go the extra mile" for colleagues and patients.

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