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Improving Retention of Med-

Surg Nursing Staff

Ashton Birdsong, Elise Myers, Alexis Reyes, Grace Sconzo & Mary
Bon Secours Memorial College of Nursing, Class of 2019
2017/2018 Turnover SFMC Med-Surg
2018/2019 Turnover SFMC Med-Surg

By December, 2020 we will

reduce the 1st yr turnover rate
of nursing staff on the 5th
floor Medical Surgical unit at
St. Francis from 25% to 10%
through implementation of
Verbal Acuity Report (VAR).
Description of the Issue: Macro
● Job turnover in Registered Nurses has
increased nationally over the past
several years (Kovner et. al, 2016).
● RN to patient ratios have been
increasing, leading to RN
dissatisfaction and burnout (Barrientos
- Trigo et. al, 2018).
● New graduate nurses commonly start
on medical-surgical floors; lack coping
mechanisms for high patient ratios.
Description of the Issue: Micro
St. Francis Medical Center: 5th floor Medical-
Surgical unit

■ RN turnover $$$
■ Average RN to patient ratios:
typically 1:6.
■ RN’s report stress and burnout
related to staffing ratios
■ Current acuity tool not being
utilized, time consuming
Analysis of the issue
● Data collection
○ Researched literature on the topic, qualitative interviews, survey monkey

○ On site observations of the unit + interviews with nurses and leadership

● Data Analysis
○ Perception of safety

○ Support from leadership

○ Quality of life

○ Availability of Resources

○ Level of experience
“Lower nurse to patient “If the ratios could be
ratio, especially with high better (5:1 max), it
acuity patients” would keep retention”
“Weekends are unsafe
most of the time.” “I love nursing, but this
unit has left me feeling
“Having 6 patients burnt out at times”
makes me feel like I can “Better staff ratios, show more
not do my job well appreciation and say when we
enough” are doing a good job
“When interviewed nurse to patient personally”
ratio discussed was 1:5, which has “Weekends are
not been the case since starting.” extremely hard”
Root Cause
● ROOT CAUSE = Staffing ratio
○ 1 nurse: 6 patients

○ Time-consuming acuity tool

○ 12 new grads hired

● Low job satisfaction -> high turnover rate

● Ensuring open communication between leadership and staff nurses
increases structural empowerment and results in a more positive perception
of the workplace (Pineau et al., 2015)
Possible solution = Visual Acuity Report (VAR)

HYPOTHESIS: Implementing a more time-effective patient acuity tool including

verbal communication between staff nurses and leadership will improve nurse

retention rates on the Med-Surg unit at St. Francis by addressing patient assignments

and saving time in determining acuity.

Verbal Acuity Report (VAR)
The purpose of this tool is to help NURSES! The verbal acuity report is a
quick, simple tool that nurses use to identify patient acuity. Parameters are
provided to help guide you in determining patient acuity, but keep in mind that the
parameters are suggestions, and we value your nursing judgement in determining
patient acuity. This tool will include a verbal report to your charge nurse during the
2nd half of your shift or when acuity status changes.
Consider whether each of your patients is a GREEN, YELLOW or RED.
General guidelines suggesting what makes a patient green, yellow or red are listed
below. Once you have assigned an acuity to each patient, have a brief face-to-
face, verbal communication with your charge nurse. Patient acuity is subject to
change throughout shift as patient condition changes. If a patient acuity is “red”,
please explain why. If patient acuity is “yellow”, but you have concerns that they
might become “red”, please explain why. Leadership will do their best to make
patient assignments for the following shift accordingly and provide help/resources
as appropriate.
GREEN (self-sufficient) YELLOW (baseline resources) RED (more than baseline resources)

-Room air or 1-3L nasal cannula -Oxygen therapy > 4L -Unstable patient (hypertension, hypotension,
-Patients undergoing diuresis -One or more of the following: nephrostomy, trach, venti-mask, non-rebreather mask)
-Pending discharge urinary catheter, urostomy, ileostomy, abscess ->1: nephrostomy, urinary catheter, urostomy,
-Minimal assist or ambulatory self-care drain, subrapubic catheter, PEG/PEJ tube ileostomy, suprapubic catheter, PEG/PEJ or
-Pain is well-controlled -Patient pending multiple diagnostic procedures complex complete care patients
-Oral and subcutaneous medications (CT, US, PT,MRI)
-Challenging patient and/or family behaviors
-Electrolyte repletion - Increased psychosocial needs
-Actively dying patient
-Basic IV antibiotic administration -Pain control q 4-6 hours
-Up ad lib or ambulates w/ 1 assist -Pain well controlled on PCA -Pain control Q2 or Q3 hours
-Stable pre-op or post-op patients -PICC line -Uncontrolled pain on PCA
-Supportive, helpful family or friend(s) at - Diabetic or HF ->1 blood product per shift
bedside -Easily addressed complete care and minimal
-Actively going through withdrawal
assist patients
-IV medications q 4-6 hours -1:1 patients (
-Heparin infusion -Complex or frequent IV medications (i.e. q2 or
-Stable alcohol withdrawal patient 3 hours)
-Pressure ulcers (q 1-2 hours repositioning) -Dual diagnosis (substance abuse and mental
and standard wound care disorder)
-Complex wound care
-Confused patients at great risk for falls
Example Green Patient

35 y/o male dx with cellulitis requiring basic IV antibiotics, minimal pain

interventions, well controlled diabetes on oral medications
Example Yellow Patient
67 y/o female post op mastectomy who is stable but needs frequent VS
checks, pain interventions q 4 hours, with supportive family at bedside
Example Red Patient

41 y/o male COPD exacerbation on 5 L O2 requiring frequent breathing

treatments, with difficult to control HTN, urinary catheter in place, with
challenging visitor behaviors.
● Stakeholders
○ Nurses on the unit (new and experienced)
○ Potential new hire nurses
○ Unit nursing leadership
○ BSHI nursing leadership
● Costs
○ MINIMAL! Markers, bulletin board, badge buddies
○ Estimated $500
● Timeline
○ Implement January 2020 after initial survey data collected
● Data Collection
○ Repeat survey at 2 months, 4 months, 6 months, 12 months
○ Survey includes perception of effectiveness of VAR, job satisfaction, turnover rate, etc. to
evaluate hypothesis
○ Anonymous data collection by unit nursing leadership oid
● Evidence
○ Creator of a similar tool New York Presbyterian, Weill Cornell Medical Center → improved job
○ Memorial Regional Medical Center → success with a similar tool
○ Utilization of VAR → more efficient patient assignments
○ Face-to-face communication = trust, minimize risks and increase benefits, improve leadership
○ and communication skills
● Logistics
○ Staff meetings
○ Badge Buddy
○ Softchalk
○ Bulletin Board
○ New Hire orientation
○ Frequent check-ins during huddle
How will the VAR address the problem?
● Patient assignments will be made according to acuity levels taking into
consideration the workload for nurses
● Nurses will have input in patient assignments and direct, face-to-face
communication with leadership
● Value of nursing judgement
● Leadership is aware when acuity is high
● Better distribution of workload on the unit
● More manageable workload —> improved job satisfaction —> decreased
burnout —> improved team morale —> incentive to stay!
● Staff nurses on unit feel supported
● Biggest cause of job dissatisfaction= staffing ratio
● Current acuity report is time consuming
● The VAR will save time and improve job satisfaction
● Face-to-face communication between staff and leadership builds trust
● Simplify patient acuity ranking to improve assignments
● Training/implementation low-cost
● The VAR has been successful within the Bon Secours System
● Follow up data to determine effectiveness
Barrientos‐Trigo, S., Vega‐Vázquez, L., De Diego‐Cordero, R., Badanta‐Romero, B., & Porcel‐Gálvez, A. M. (2018). Interventions to

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Jones, P.,A. (2015). What works: measuring acuity on a medical-surgical unit. American Nurse Today. Retrieved from


Kovner, C. T., Djukic, M., Fatehi, F. K., Fletcher, J., Jun, J., Brewer, C., & Chacko, T. (2016). Estimating and preventing hospital

internal turnover of newly licensed nurses: A panel survey. International journal of nursing studies, 60, 251-262.

Pineau Stam, L. M., Spence Laschinger, H. K., Regan, S., & Wong, C. A. (2015). The influence of personal and workplace resources on

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