Agents of Change
Hospitals successfully wean themselves from agency nurses and channel savings into developing ways to keep employees and patients satisfied

By Heather Stringer
December 18, 2003

On July 1, Community Health Network in Indiana took the plunge: The five hospitals in the network stopped using agency nurses.

For the facility's chief nursing officer, Janet Bingle, MS, RN, the biggest challenge was fighting the fear that the facility wouldn't have enough nurses once it made the shift to being agency-free. Yet it successfully made the transition-an endeavor that required nothing less than two years of intense planning.

Community Health Network is not alone. Hospitals throughout the country are cutting back on the use of agency nurses. Although hospital executives may initially be motivated for financial reasons, they agree that the facilities are reaping much greater benefits as long overdue changes are made to prepare for the transition.

In order to gear up for agency-free deadlines, hospitals have poured money and resources into not only hiring more nurses, but also coming up with strategies to keep existing staff nurses happy.

Several hospitals tackled the challenge of improving nurse employee satisfaction by working to earn Magnet status. At The Methodist Hospital in Houston, the Magnet journey led the hospital to give nurses a greater voice in the hospital's governing councils. These councils work through problems that are identified in different units.

For example, nurses in one council worked on methods to reduce the rate of bedsores among patients. The team came up with the idea of purchasing mattresses that could better relieve pressure.

Valerie Jackson, RN, a nurse in the cardiac intensive care unit at Methodist, is a member of the hospital's research and education council.

"I'm interested in research and new products, and being on the council makes me feel like I am more involved and more accountable," she said. "I also feel like I'm making a difference."

Although it was critical to retain staff nurses, Methodist executives also knew they needed to beef up recruitment of new nurses if there was any hope of eliminating agency use. To that end, the hospital created a nursing internal flex team. The nurses they hired for the team would earn a higher wage and have a more flexible schedule, but they would not have employee benefits. These nurses also would differ from agency nurses in that they'd be expected to participate in hospital orientations and annual reviews.

The hospital also developed a more sophisticated float process as a second buffer for high patient-count days or to cover sick or vacation time for staff nurses.

Unexpected benefits

Before Methodist developed these programs, the facility was spending about $1 million per month on agency nurses. It has been agency-free since the beginning of the year, and the reward has been far from just financial, Tricia Lewis, MS, director of the coronary care unit, said.

"The reward is the satisfaction that we've been able to provide the patients with a high level of care," she said. "Patient satisfaction has continued to improve, and the physicians are also happy because they don't have to deal with nurses they have never seen before."

Staff nurses also enjoy having more time to focus on patients, Jackson said.

"It's a big change to no longer use agency nurses," she said. "It's improved the consistency of care because [staff nurses] better know each other's strengths and weaknesses. It also takes time to show agency nurses where things are and how to do different tasks, and it gave me less time with the patients."

A recent report by the Institute of Medicine [see "Working conditions require 'substantial changes,' " Nov. 17 issue] suggests that reducing agency use is also critical because it cuts down on the risk of medical errors. The report, released Nov. 4, stated that "Whenever possible, health care facilities should avoid using nurses from temporary agencies to fill staffing shortages."

Although retention strategies are critical to reducing dependency on agencies, nurse executives said it would have been impossible to meet this goal unless hospitals also are willing to pour resources into hiring more nurses.

Bingle decided to go directly to the agency nurses to see if there was a way to attract them to be employees. She interviewed agency nurses and asked why they worked for an agency rather than the hospital.

"Lots of people think it's the money that attracts them to agencies," Bingle said. "But the nurses I talked to wanted the freedom to say when they were going to work and didn't want to be bugged all the time."

Bingle took this information back to the hospital's human resources department and came up with the idea of creating a 13-week traveler program for people who lived in the community.

These local traveler nurses would work the shifts that were difficult to fill at the hospital, such as evenings and nights, and the travelers could decide which 13 weeks they wanted to work.

Bingle's facility also developed a refresher program that attracted
anywhere from six to 16 students per class, and the hospital hired about 70 percent of the nurses who completed the program.

The facility also created a program that allows staff nurses to work additional hours to earn extra money.

All for one

Although she credits the human resources and nursing departments for toiling every week to prepare the agency-free deadline, Bingle said it would not have been possible without the support of the top leaders in the hospital.

"It has to be a strategic imperative of the whole organization," she said. "It can't just be a nursing thing. We had support all the way up to the CEO. It can't be people down here hoping. Hope is not a plan. You have to have a plan."

While many hospitals are attempting to eliminate agency use altogether, others are zeroing in on the departments that use agency nurses most heavily.

At Community Memorial Hospital of San Buenaventura in California, hospital executives found that registry nurses were often hired in critical care units. To change that pattern, the hospital started an internship program for employees who wanted to train to become nurses in critical care units.

The hospital continued to pay employees as they participated in the program, which offered specialty training in labor and delivery, the OR, the emergency department or the ICU. About 12 students graduate from the program per year.

Rhonda Spiegel, MPA, RN, assistant director at the hospital, said that these graduates help the hospital avoid using as many expensive agency nurses, and some of the money saved is funneled back into the program.

"It is a trade in dollars," Spiegel said. "Some of the dollars we are saving in reduced registry we are spending in the program.

"In the long term, though, it puts us in a better position, and is better for patient satisfaction. We'd rather have a competent nurse who wants to stay than the revolving door of the agency."

Successful strategies

Like her nurse executive counterparts, Kathy Walsh, MS, RN, chief nursing officer at Memorial Hermann Southeast Hospital in Houston, agreed that it was daunting at times to stop relying on agencies, and the hospital's success hinged on tackling the problem on several fronts.

One of the facility's most successful strategies was finding ways to attract student nurses to do rotations at the hospital. It hired a nurse who would teach at the nursing school, and these students performed rotations with her at Memorial Hermann. Now, the hospital has about 70 students who do rotations each year, compared to only about 10 in the past. So far, the hospital has hired about 23 students by forging these connections with the local nursing school.

To attract more people to the hospital, Memorial Hermann also offered classes for nurses that would give them continuing education credits.

The hospital wanted to draw both new nurses in search of jobs and also seasoned nurses who wanted to work in a different hospital.

The hospital also experimented with a phone-a-thon in which job candidates could call in and be guaranteed an immediate phone interview. The hospital advertised heavily in those areas that were not experiencing an acute nursing shortage.

These tactics in combination with others allowed the hospital to cut its vacancy rate from 18 percent to 2 percent, and the facility now is not using any agency nurses. The hospital also has doled out some of these savings to a bonus for each employee.

Now that the hospital has weaned itself of agency nurses, employees and administrators expect that their efforts will last.

"I've been through other shortages, and I knew the payback would be there," Walsh said.

"It was a little bit scary sometimes, but we knew it's what we had to do. When you invest in the nursing environment, you keep people in the long run."

Contact Heather Stringer at heather_stringer@yahoo.com