Does recent Colorado policy effectively address nurse retention?
By Victoria Jennrich DMSG Student Intern
University of Colorado-Denver
Research Question: Does recent Colorado policy effectively address nurse retention?
- Issues of nurse retention are not new but highlight a decades-long problem.
- COVID-19 further illustrates the urgent need to address nurse retention.
- Around 200,000 nursing positions per year are expected to be vacant through 2030.
- The average cost to turn over a registered nurse is $40,038.
- Colorado updated its Standards for Hospitals and Health Facilities in October of 2021 which includes nursing services.
- The ten standards listed under Part 14: Nursing Services of Chapter 4 regulations were directly compared against themes pulled from a brief literature review of nurse retention.
- Results were based on how many times a standard from Part 14 aligned with one or more of the themes.
- Staffing, clarity of expectations, and self-governance were the three factors of nurse retention that were observed in the Nursing Services section of Chapter 4 regulations.
- There is room for improvement in addressing nurse retention factors such as collaboration and teamwork, opportunities for growth, leadership, and recognition. These themes may be difficult to regulate on a legislative level because of differences in organizational cultures.
- The findings pave a way for further research on whether the nurse retention factors addressed in Chapter 4 revisions provide notable improvement in nurse retention.
*(Colorado Hospital Association, n.d.)
Does recent Colorado policy effectively address nurse retention?
Alongside urgency for personal protective equipment, or PPE, COVID-19 has set the stage for a more chronic issue to reemerge: the nursing shortage. Popular media surrounding buzz words and phrases such as ‘the great resignation’ is perhaps not new to the nursing world but have been exacerbated by work demands onset by COVID-19. In addition to the compounding stress that COVID-19 added to the nursing workforce, less boisterous is the phenomenon that nurse retirement rates are outmatching their replacement rates (American Nurses Association, n.d.). Nurse education is limited by a lack of nurse educators which in turn restricts enrollment and graduation rates from adequately replacing retiring nurses (American Association of Colleges of Nursing, 2020). Demand for nurses is furthermore increased by an aging population and growing incidence of chronic medical needs. The perfect storm that is the nursing shortage draws even more stress, burnout, and turnover of our existing nurse workforce.
As the nurse workforce stands, the Bureau of Labor Statistics (2022) estimates that an average of 194,500 registered nursing jobs will be open annually for the next decade. During the pandemic, however, an increased use of traveling nurses has been employed as a strategy to supplement vacancies in hospitals. The high cost of using travel nurse agencies as a permanent solution is unsustainable for health systems, however that argument is beyond the scope of this paper. According to Becker’s Hospital CFO Report (2021) 83% of registered nurses (RN) turned over since 2016. In 2020, the turnover rate was 18.7% which was 2.8% higher than the prior year. Additionally, the Becker report cited that the average cost to turn over an RN is $40,038. While these figures vary with specialty, the aforementioned insights and statistics demonstrate a crucial need to retain the nurses already on staff.
Recent Colorado legislative revisions are perhaps a step in the right direction. October of 2021 marked the effective date for revisions to Chapter 4 of the Code of Colorado Regulations (Colorado Department of Public Health and Environment). Chapter 4 is a section of the Standards for Hospitals and Health Facilities that concentrates on regulating acute care hospitals. Of the revisions, a major theme emerged around Part 14: Nursing Services that aimed to empower nurses, set standards, and increase oversight of hospital compliance and master nurse staffing plans (Colorado Hospital Association, n.d.). The Colorado Hospital Association commented that the “revisions to Chapter 4 set a standard for nurse staffing while ensuring the ability of frontline nurses to contribute to decision making through shared governance.” As a relatively recent development in legislation focused on nursing mixed with the current state of the nursing workforce and the challenges it faces, this study asks the question ‘does recent Colorado policy effectively address nurse retention?’ The researcher’s hypothesis answers in the affirmative.
For the purposes of this article, I will take a broach approach to retention that suits the breadth in the research. Therefore, I will define retention as keeping employees within their department of an organization which will be used antonymous with turnover. Staff members who migrate to different areas of an organization are treated as though they have left. These ideas may be loosely described with measures such as job satisfaction and burnout as detailed in the literature, however, the difference should be noted that staff members may burn out or be dissatisfied yet remain at their employment due to outside motivators (providing for family, paying bills, etc.). Since the research themes are common across various definitions of retention, a broad approach appears to suffice.
Method of Analysis
A literature review was conducted using the database CINAHL (Cumulative Index to Nursing and Allied Health Literature). Search terms included “Nurse AND retention.” To narrow the 9,288 returned articles, added parameters were as follows. The search was limited to articles with ‘Linked Full Text’, ‘English Language’, ‘Peer Reviewed’, ‘Research Article’, from 2017-2022, with ‘USA’ as a designated Geographic Subset. The returned search listed 47 articles of potential matches. After reviewing the abstracts of the article list, 14 articles were determined to have potential relation to the topic of nurse retention. Articles relating to clinical research, that were beyond the scope of the United States, and that appeared similar yet unrelated to the scope of this project (i.e. nurse retention in schools, turnover without mention of retention, and residency programs for nurses) were omitted.
A detailed review then ensued of the 14 articles. During the literature review, four additional articles were excluded from further analysis that were determined to be outside the scope of this topic. Major themes of the ten remaining articles were compiled in which further subcategorize what nurse retention encompasses to assists the comparative analysis of Chapter 4 revisions. These categories include adequate staffing, clarity of expectations and duties, the importance of self-governance in decision making, collaboration and teamwork – between nurses, nurses and physicians, among administrative staff, and leadership, opportunities for growth (educationally and career-wise), the transparency, authenticity, and trustworthiness of leadership, and finally, recognition. Uncommon themes such as the ‘preparedness to handle ethical dilemmas’ were excluded to increase the generalizability of analysis. Using these seven primary characterizations, I analyzed the 10 standards listed under Part 14 of Chapter 4 relating to nursing services. If a standard contained multiple provisions that encompassed more than one primary characterization, it was included in both. The results are detailed more in the discussion below.
Results and Discussion
Results of analysis are shown in Figure 1. Of the ten standards listed under Section 14, two did not receive any categorical designation based on the literature review themes. The remaining eight regulations of Section 14 were strongly confined to three of the seven literature review categories of staffing, clarity of expectations and duties, and self-governance. Standards relating to staffing regarded master nurse staffing plans, a minimum requirement for registered nurses and auxiliary personnel per unit, and a nurse staffing oversight process. Clarity of expectations and duties took form in policy and procedure implementation, a nurse staffing oversight charter, and directly in standard 14.7 that the “responsibility of each nurse and auxiliary personnel shall be clearly-defined in written policies.” Lastly, self-governance was considered whenever the standard called for a qualified registered nurse to participate in leadership positions (different from the leadership category defined by trustworthiness, authenticity, and transparency) and a call for “at least 50% or greater participation by clinical staff nurses” in the nurse staffing oversight process.
Figure 1. Results of Comparative Analysis between Literature Review Themes on Effective Retention Categories against Chapter 4, Section 14 Code Revisions.
These three areas – staffing, clarity of expectations, and self-governance – directly align with how the Colorado Hospital Association defined the changes made to this section of Chapter 4. As a result, the hypothesis that recent legislation effectively addresses nurse retention is affirmed. However, results remain up to the organization on this multifaceted issue. While Chapter 4 standard changes are a step in the right direction towards nurse retention, they will also provide meaningful data for next steps on the road of continuous improvement in the nurse staffing world.
There appears to be improvement opportunities in the remaining areas: collaboration and teamwork, opportunities for individual growth, leadership, and recognition. One finding to note is that leadership by way of placing nurses in leadership roles was present in the standard changes, however the pairing was deemed as inconclusive on whether the standard fell under the leadership category. The intended operational definition of leadership regarded transparency, authenticity, and trustworthiness which was determined to be beyond the scope of leadership and leadership roles observed within the Nursing Services section. These improvement areas, like seen in the leadership category, are more difficult to regulate at an objective, legislative level, and are highly variable to organizational culture.
The state of nurse staffing is not a new phenomenon but has been exacerbated by the stressors of COVID-19. Nurse turnover rate has been increasing in recent years, which is financially and emotionally costly to healthcare organizations. This article’s aim was to assess whether Colorado legislation begins to address issues surrounding nurse retention as defined by recent literature. Articles that have emerged in the last five years surrounding nurse retention appear to support the actions taken in Colorado legislation in regard to staffing, clarifying expectations and duties of nurses, and including nurses in governance of operations. There is still room for growth in other areas which will rely on hospitals and health systems to take the lead and adapt to their culture. Only the future will tell, however, if these steps are the right ones and whether research needs to take another look at the complex topic of nurse retention strategy.
This study faced several limitations. From the literature, there appears to be no standardized definition of retention. To further research on the topic, it would be beneficial to utilize a similar understanding of the topic – wary of fallacies that surround retention (such as using job satisfaction as a measure of retention). Additionally, to improve generalizability of the categories obtained in the literature review, terms such as leadership take on several meanings such as individual relationship, trustworthiness, support, and transparency. Specific operational definitions would be beneficial to define in the future. Lastly, application of the categories to the standards listed in Section 14, because of their broadness, were subject to a degree of subjectivity. However, the results align with the comments made by the respected Colorado Hospital Association, which credit their validity.
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About the Author:
Victoria Jennrich is a Student Intern with Denver Medical Study Group. She just recently received her Master’s in Business Administration with a specialization in Healthcare Administration at University of Colorado-Denver this past May.