With RN vacancy and turnover rates hovering at a national average of 11 percent and 13 percent, respectively, acute care executives are keenly aware of the critical necessity to retain personnel—and frequently welcome suggestions from staff. On the frontlines of healthcare, nurses not only are valued members of patient care teams, but also have the unique ability to evaluate the functionality of their units. Input on day-to-day operations—from floating, to safety, to interpersonal relationships—can provide management with clues on how to promote better patient care and employee satisfaction, while increasing retention. Read on as representatives from three hospitals offer a glimpse into strategies for improving conditions in the workplace.

Closed-unit staffing Centra Health Inc., Lynchburg, Virginia

Like so many healthcare systems, Centra Health Inc. had been dealing with substantial nurse turnover rates for years, averaging 14.3 percent at its 500-bed hospital in 2000. Relying on new graduates from its diploma and two affiliated BSN programs and more experienced nurses from three in-house float pools to cover short-term staffing needs, the organization still did not have the resources to fill all open vacancies. To maintain quality of care throughout the facility, supervisors juggled schedules, pulling permanent staff from regularly assigned units to float to positions elsewhere in the hospital.

In fact, floating had become a routine element of the workday. "Every shift had a floating occurrence and nurses quickly learned how to manipulate the schedule," says Gwen Hartzog, MSHA, RN, CCRN, director of medical/surgical and critical care nursing. "If the patient census was low, some nurses would call in sick rather than being told to float."

This absenteeism only complicated an already strained system, and was an indicator of the displeasure floating created among nurses. When Golden H. Bethune, MSN, RN, CNAA, BC, senior vice president of patient care services, arrived at Centra Health that year, she quickly discovered just how unhappy the RNs were about the policy. During the town-hall meetings she established, nurses openly expressed their concerns about being pulled. "Floating to other units was the number one dissatisfaction among nurses," states Ms. Hartzog. "They prefer to stay in one unit where they have expertise and a level of comfort."

Among the proposed solutions offered during the town-hall meetings was the idea of closed-unit staffing. This organizational approach commits nurses to only one unit. Those professionals who wished to cross-train in another specialty could volunteer to float at their discretion.

In theory, closed-unit staffing sounded like a logical solution. Yet, it was virtually untested in the industry, and there were questions about its viability. "My concern was that we absolutely needed to have adequate coverage at all times," Ms. Bethune notes. "However, I recognized that there are departments in every hospital—the operating room, labor and delivery, and recovery—that do not allow their nurses to be pulled. So I asked myself, 'If those areas could function without floating, what is stopping the rest of the units from adopting the approach, too?' We used them as benchmarks for our program."

Making a commitment. Immediately, a task force was formed to research closed-unit staffing. The four-person committee consisted of managers from MICU and VICU, med/surg, PACU, and pediatrics and outpatient. The group's duty was complicated by a lack of available data. A member herself, Ms. Hartzog says, "We did a massive literature review and could only find one article that had utilized the closed staffing model."

Despite the minimal amount of published material, the task force was able to glean a great deal of advice. Ms. Hartzog explains, "We learned that we could not trial the process. That would send a negative message that we might go back to the way it had been. We wanted everyone to know we were definitely making a commitment to change."