To keep nurses at the bedside, get them involved in leadership

Hospitals have spent the last few years trying to figure out how to retain nurses.

And when I walked through the poster session at this year’s American Nurses Enterprise Magnet/Pathway conference, I found a common theme on display. To keep nurses engaged, poster after poster showed, hospitals need to invite them into the decision-making process.

It may sound obvious, but nurses have been underrepresented in top leadership positions. Nurses hold only about 5% of seats on hospital boards – and only 43% of hospitals have any nurse representation on their boards at all, compared with 80% of hospitals that have at least one physician board member, according to 2022 data from the American Hospital Association .

“Why is it that our largest healthcare workforce – who are at the bedside – doesn’t have a seat at the table?” said Danielle Altares Sarik PhD, APRN, CPNP-PC, FAAN , director of nursing research and evidence-based practice at Nicklaus Children's Hospital Foundation . “If there aren’t opportunities, they’re just going to jump ship to the places that will pay them the most – and you can’t blame them.”

Even the way hospitals talk about time away from the bedside – labeling it “nonproductive time” or “nonproductive hours” – sends the wrong message about the importance of enrichment and continuing education, she added.?

That stigma persists despite ample research linking well-staffed, highly-educated nursing units to better patient outcomes.?

The Commission for Nurse Reimbursement , which was formed earlier this year, is trying to push forward on this issue, advocating for nursing care to be billed and reimbursed like other clinical services, rather than rolled up into hospital labor costs.

“Nursing hours are sometimes measured against what we believe are antiquated measures,” said Rebecca Graystone, PhD, MBA, RN, NE -BC , vice president of the American Nurses Credentialing Center’s Magnet Recognition and Pathway to Excellence programs. “What we battle oftentimes in healthcare is for people to understand the financials. … Nurses aren’t ‘cost centers’ but revenue generators.”

The ANA’s Magnet program aims to reward hospitals that empower nurses to deliver better patient outcomes and encourage more nurse innovation. Pathway to Excellence, meanwhile, recognizes hospitals that have supportive practice environments, including having nurses involved in decision- and policy-making.?

In that way, shared governance is baked into both recognition programs, Graystone noted. “We believe the voice of the nurse is critical to the success of healthcare organizations,” she said.

To assess the impact that nurses have, the programs evaluate how hospitals perform on measures that are uniquely within the domain of nursing, or what Graystone described as “nurse sensitive indicators.” One example would be initiatives to reduce the number of patient falls.

Poster after poster at the conference highlighted innovations coming out of Magnet and Pathway-credentialed hospitals – and showed the importance of having nurses involved in leadership and decision-making.?

“Part of our evidence-based standards are all driving toward the ‘so what’ question,” Graystone said.

A number of hospitals shared results from shared governance initiatives, including nursing councils that gather feedback from different units, either to address problems or bring them to the c-suite. The results have been telling:

• HCA Houston Healthcare has had shared governance for about 10 years now, but participation was low, hovering around 20% in 2020 and as low as 10% in 2021. But it was able to increase involvement to 80% last year by restructuring the format, said Joan Kelley , vice president of nursing initiatives and accreditation. Nurses were instructed to bring not just their complaints but their solutions, and representatives from other departments (like dieticians and phlebotomists) joined meetings to address specific concerns. “When you give people a voice and they see that voice being heard, it keeps people coming back,” Kelley said.??
• Indiana University Health , which introduced a nursing council in 2018, decided to divide the group into six smaller councils to better address the distinct issues that different units face. Nurse engagement increased 23%; nurse turnover was cut in half between 2020 and 2022; and nurses even had more abstracts accepted to conferences. Patient satisfaction also increased as happier nurses led to happier patients.

• Nursing leaders at Robert Wood Johnson University Hospital conducted a survey in 2021 to get feedback from nurses on how well its unit-based councils were working. And what they found was that nurses who were involved with the councils felt more connected to the hospital, more empowered to make decisions and that they were gaining skills that would help advance their careers. But the survey also identified barriers to participation, such as inadequate staffing, which can now be addressed. “We got responses that opened our eyes on how these councils helped them grow,” said Kathy Easter , assistant vice president for nursing excellence. “A lot of the work that they do is to improve patient outcomes. [But participation] not only improved clinical practice … it also serves as a leadership pipeline.”

Graystone encouraged nurses who are job hunting to press hospitals about their nurse engagement and shared governance initiatives, adding, “We cannot afford one single nurse who is at the beginning of their career to leave the profession because of a bad experience.”