Anoka-Metro Regional Treatment Center’s Staff Retention Essay

Introduction

Anoka Metro Regional Treatment Center is located in Anoka, Minnesota, and is one of the largest high-security psychiatric hospitals in the area (MDHS, 2020). Its current operating capacity is at 110 beds, having dropped from 200 in the wake of various staff retention problems that have been occurring since and well before 2018 (MDHS, 2020). The hospital provides a critical service to the community by focusing on long-term treatments for individuals sentenced to mandatory psychotherapy as a result of a civil court decree or pending a criminal trial. The hospital has a general psychiatric ward of 200 beds, a special ward for patients with chemical dependency, two independent community wards (16 beds each), as well as spaces for community-based support programs (MDHS, 2020). The purpose of this proposal is to restore the hospital to its full operational capacity by improving nurse and employee retention.

Clinical/Organizational Problem

The identified clinical/organizational problem within Anoka Metro Regional Treatment Center is nursing retention. It stands for the ability of the hospital to attract new talent while retaining existing employees in order to keep all of the vacancies occupied. An organization that in uncapable of retaining its staff suffers from a variety of side-effects, some of which include rising expenditures, a drop in the quality of care due to inexperience, poor working cohesion between different team members, increased rates of care fatigue, higher numbers of professional mistakes, and various other issues. Rising expenditures come from the money and time needed to find and fully introduce a new employee into the organization. These losses are estimated between 2 to 7 of monthly salaries per employee, which negatively affects the budget (Imo, 2017). Quality issues, a lack of cohesion, and professional mistakes all stem from the relative lack of experience – in a roster that keeps changed every few months due to nurse losses, it is hard to build team spirit. Care fatigue is related to the same issue – in a team where more experienced members can shoulder some of the burdens until a newbie is ready to fully carry their own weight, fatigue can set on early and result in a loss of an employee within 1-2 years since their enrollment (Imo, 2017). Therefore, the identified organizational problem is extremely important in the context of Anoka Metro Regional Treatment Center’s current situation.

Description of the Problem

The hospital is experiencing a severe nursing shortage in the wake of failing to maintain suitable working conditions for nurses. AMRTC was notorious for having one of the highest rates of patient-to-nurse violence rates in the region as well as numerous examples of patients managing to escape the highly-secured facility, generating distrust for measures utilized to ensure nurse and patient safety (MDHS, 2020). According to the official statistics, AMRTC is currently missing 16.8% in clinical personnel and 11.5% in direct care positions (“Quarterly report,” 2017). Clinical positions include mental health professionals (psychologists, psychiatrists, and social workers engaging with treatment teams), and professional staff members that provide services outside of the supervision of direct care positions (“Quarterly report,” 2017). Direct care positions, on the other hand, include the day-to-day care for patients 24 hours a day 7 days a week, as well as direct services under the mandate of a MH professional (“Quarterly report,” 2017). Examples of such include occupational and recreational therapist, as well as human services technicians.

This problem needs to be addressed with an innovative and evidence-based approach, due to the fact that nurse retention has a direct impact on the hospital’s performance, patient-centered outcomes, and the overall quality of care. A lack of nurses prevents AMRTC from operating at its peak capacity, denying patients the required care that could not be readily provided in the area. AMRTC serves Anoka, Dakota, Ramsey, Scott, Sherburne, Washington, and Carver counties, meaning that individuals who do not get treatment on site will have to be allocated to other areas, effectively displacing them and complicating family visits (MDHS, 2020). In addition, a high patient-to-nurse rate means individual patients get less care, and often have to wait for extended periods of time to obtain it. As a result, the quality of care may drop, and unwanted side-effects of neglected treatment may affect patients and nurses alike. Finally, the lack of specialists prevents AMRTC from operating some of its facilities, namely the detox and chemical abuse departments.

Explanation of Causes

One of the primary reasons for AMRTC having a low retention rate, along with a substantial percentage of open vacancies, is the fact that mental health hospitals are inherently more dangerous than regular wards (Imo, 2017). In 2017, one year prior to the boycotts and mass exodus of personnel, the average number of OSHA-recordable cases of injuries and aggressive behavior was 31 cases per quarter (“Quarterly report,” 2017), which is incredibly high. Nurses who fear their patients and worry for their health and well-being are more likely to quit their job and look for a safer place of work (Imo, 2017). Although some measures have been taken to improve nurse safety, the reputational losses made the hospital difficult to restore the original numbers of employees to operate at peak or near-peak capacity (MDHS, 2020).

The second cause of low retention rates at AMRTC is due to the nature of treatments they provide. Mental health clinics in general have lower retention rates, no matter the quality of care, nurse safety, and compensation rates (Jansen, Hem, Dambolt & Hanssen, 2020). Mental health services are inherently more physically and spiritually taxing on the nurses than regular health operations, as they often require 24/7 supervision (Jansen et al., 2020). It also demands a close connection with the patients, their worries and troubles, as well as, as it was mentioned before, a certain level of risk to personal safety (Jansen et al., 2020). As a result, the conditions are particularly taxing on the personnel, especially the newer recruits that do not have the same levels of mental resistance and experience when compared to the skeleton crew of the hospital. As a result, they are much likely to drop, contributing to the statistic of nearly 35% of all nurses to leave the profession within 1-2 years of service (Jansen et al., 2020).

The third cause of low retention rates in AMRTC is likely related to a lack of superior compensation packages. The average salary for a mental health technician, which is a full-time employee providing 24/7 care, is rated at 22.7 USD per hour in Anoka, Minnesota (“How much,” 2020). At the same time, the median salary for a MH technician in the US is at 35.33 USD per hour, meaning that employees at AMRTC are underpaid for the services they provide and risks they take (“Mental health technician salary,” 2020). This results in a lower desire in nurses to give their all during work, especially when there are alternatives to find employment in less strenuous working environments, for higher compensation. In other words, AMRTC is losing out by providing a less-than-competitive salary for a high-risk position of employment.

Outdated scheduling methods constitute a potential reason for high nurse turnover rates in AMRTC. As it stands, the hospital implements 12-hour shifts, which are notorious for being criticized within the nursing community for causing stress, fatigue, and general tiredness (Johnson et al., 2018). Not to mention, 12-hour shifts often turn out to prolongate for 2-4 hours beyond the norm, in order to cover up for various inconsistencies and scheduling failures that are caused by a chronic lack of personnel (Johnson et al., 2018). Employees who work past the point of tiredness are more likely to suffer from burnout and leave the profession (Johnson et al., 2018). In addition, prolonged exposure to such leads to ruined work-life balance, poor sleeping schedules, and a variety of mental issues that may contribute to high turnover rates (Johnson et al., 2018).

Finally, there is a lack of nurse-dedicated interventions with a specific objective of reducing stress, anxiety, and fatigue. Many hospitals, both general and psychiatric, implement a system of non-monetary rewards and spiritual relaxation, including meditation, massages, and other physical or behavioral means of reducing stress (Johnson et al., 2018). AMRTC does not have a dedicated intervention to do that. Because of this, the hospital is losing more nurses than it should, as such a behavior inadvertently shows a lack of care for retention, which is being sensed by the personnel.

Identification of Stakeholders

The primary stakeholders involved in the proposed solution to the problem of nurse retention are as follows (Wu, Wang, Tao, & Peng, 2019):

• Patients. They are the primary stakeholders, as all and any interventions have the underlying motive of improving the quality of care. If nurse retention is increased, patients will enjoy better treatments, shorter waiting times, greater likelihood of receiving accommodations, and a better overall treatment (Wu et al., 2019). Although this group has an inherent interest in the success of the intervention, their ability to influence the process is relatively limited due to the nature of their ailments.
• Nurses. This large group also constitutes the primary stakeholders, as the point of the proposed intervention is aimed at them. They have a keen interest in the measures proposed in this paper, as it promises an increase in the quality of work for them, thus enabling them to work with their patients safely (Wu et al., 2019). This group of stakeholders has demonstrated the will to see changes happen, as evidenced by the boycotts of 2018 and onwards (MDHS, 2020).
• Administrators. They constitute the third group of primary stakeholders, which will be involved in the intervention. They have the means of facilitating the measures proposed in this paper, and have a keen interest in keeping as many nurses attending their duties as possible, while ensuring the safety of all parties involved. If successful, they will be able to close out vacancies, balance out schedules more effectively, and provide care in a safe and timely manner (Wu et al., 2019).
• Community. A major secondary stakeholder. Although they are not actively engaged in the process, they are some of the beneficiaries of the changes being proposed. Should AMRTC become fully operational as a result of better nursing retention, many of the local mental health patients will be able to receive treatment in that hospital rather than being forced to send patients to other counties and regions, which is associated with complications and expenditures (MDHS, 2020).
• Local government. The authorities are largely interested in reduced patient complication rates, reduced expenditures per patient, increased salaries, and increased community prosperity (Wu et al., 2019). Should the proposed intervention work in AMRTC, this stakeholder will be satisfied.

Discussion of Stakeholders

The identified stakeholders will have different roles, based on their position and the capacity to get themselves involved in the proposed changes (Bravi et al., 2013). Nurses and hospital administration will have the roles of active implementors of the proposed solution. Patients and nurses will be the primary recipients of positive changes, with patients having a passive position in the matter. Secondary recipients of benefits would be the hospital administration and the surrounding community (Bravi et al., 2013). Local government is identified as a tertiary recipient, as the positive effects from the intervention would have an impact on some of the important metrics (Bravi et al., 2013).

Stakeholders can be classified based on three axes, which include interest, power, and influence (Auvinen, 2017). Interest constitutes the desire to see changes through. Power constitutes the capacity of the party to influence project results directly, whereas influence stands for utilizing indirect methods to support the project. Patients have high interest, low power, and low influence on the project due to the nature of their stay in the hospital (Auvinen, 2017). While they are capable of complying or resisting changes, their behavior is ultimately being moderated by hospital personnel. Nurses have a high interest, high power, and moderate influence on the project, as they are going to be the ones organizing it (Auvinen, 2017). However, their relations to indirect stakeholders is smaller, in comparison. Administrators have high interest, moderate power, and high influence, as they facilitate the conditions necessary for the intervention to be a success (Auvinen, 2017). They do not directly get themselves involve with the project, instead using nurses as an arm. Community has moderate interest, low power, and moderate influence on the process (Auvinen, 2017). While they do not directly get themselves involved in the process, they have the potential to promote their interest through affiliated stakeholder groups, namely the administration and the government. The local authorities have moderate-low interest, low power, and high influence on the project (Auvinen, 2017). While the happenings in one hospital may not be enough to facilitate attention, they have the potential to bring the full scope of affiliated powers to participate in the project.

Explanation of the Project

In order to achieve the goal of improving nurse retention, a direct intervention in the existing status quo is needed. The project will address the issue by changing the existing policies, practices, and compensation methods currently implemented in AMRTC. It will involve the collaboration of stakeholders on all levels as well. The project will seek to increase nurse retention through affecting the existing barriers and improving the nurses’ view of their own position by offering concrete and specific means through which that can be accomplished. The project will affect patient-nurse, patient-administration, and patient-community relations, over the scope of one year. It will have three parts to be attended to in a consecutive order, each affecting the other in order to achieve a cumulative effect. The proposed solution is estimated to allow AMRTC to fill out its vacancies and allow for a transfer from 12-hour to 8-hour shifts. The discussion of the proposed solution can be found below.

Proposed Solution

The proposed project involves a multi-vectoral approach towards improving nurse retention in AMRTC, aiming at the major problems identified in the Causes section. Namely, these are the safety of nurses, comfortable scheduling, and proper compensation. Nurse safety is the primary objective to improve retention, as it was the reason for the boycotts of 2018, where nurses demanded better conditions of service for themselves, as well as better security (MDHS, 2020). Their demands are understandable, as the employees of AMRTC have to deal with individuals who may present danger, having been convicted or pending convictions of violent crimes. In addition, patients with schizophrenia may have violent symptoms or misinterpret nurse activities, putting both in jeopardy. Nurse security can be achieved utilizing a system of gradation for patients based on their likelihood to incite violence, giving them 3 colors of danger – green, yellow, and red, with security measures increasing for individual patients (Halter et al., 2017). That way, inexperienced nurses would avoid treating violent patients, and resources for security may be spent more appropriately.

The second part of the project would involve increasing nurse compensations. This part of the solution may occur only after initial gains in retention would be achieved as a result of better nurse security. Should all vacancies be closed, the hospital will receive more revenue while not spending as much on recruiters and nurse scouting (Yuniarti & Tutiany, 2019). That money could be directed towards improving the salary of nurses, thus increasing their enjoyment of the workplace and the feeling of being appropriately compensated for their troubles. This segment of the intervention would effectively increase AMRTC’s competitive position in the job market.

The third part of the intervention would involve a shift from a 12-hour schedule to an 8-hour or a flexible schedule for nurses. This solution would be implemented only after the first and second stages are in progress, as the 8-hour shift model requires more nurses to be available at hand (Schroyer, Zellers, & Abraham, 2020). Therefore, under the current conditions, it is impossible to implement the proposition straight away. Nevertheless, once engaged, it would enable a smoother scheduling and patient-handling process, since the hospital would have more employees to cover all the necessary positions. In addition, shorter shifts would contribute to a better life-work balance, reduce burnout, and improve staff retention, making up for the greater numbers’ requirement for nurses.

Conclusion

Nurse retention is an important component of healthcare organization and administration and has a direct impact on the quality of care, patient recovery rates, economic compensation of hospital wards, and community service (Halter et al., 2017). At the same time, interventions have different effect on nurses depending on how well-established they are in the profession. Mills et al. (2017) reports that interventions aiming at the improvement of self-conceptualization, practice environment, and overall resilience are most impactful on nurses that have been working in the field for 5 years or less, whereas those aimed at monetary compensation show equal parity among all ages. Nurses with a history of service are reported to have developed their own coping mechanisms making them less likely to leave the profession entirely, though likely to consider changing hospitals, if the opportunity presents itself (Mills et al., 2017).

The subject of monetary compensation is discussed among other interventions in a study by Kossivi, Xu, and Kalgora (2016), who highlight the importance of the factor in young specialists. They explain the prevalence of physical rewards over non-material ones by the lack of the initial attachment to the workplace and the team among new employees and young recruits (Kossivi et al., 2016). The initial buy-in, thus, must be something tangible and easily-perceived, to make the hospital in question more attractive and more likely to retain its employees over a long period of time. Kossivi et al. (2016) also point out that the demands for monetary compensation are higher for hospitals that are associated with difficult and dangerous work. Acute care, emergency care, and stationary psychiatry are among the fields where employees demand a higher standard of pay.

Personal safety is among the most important factors to affect retention in psychiatric nursing. Barbé, Kimble, Bellury, and Rubenstein, (2018) report that the nursing opinion on the matter of nurse-patient relations is that while patient lives and health are important, they do not outweigh the requirements for nurse safety. In other words, if patients are to receive help – nurses and doctors are to be protected first. This opinion is prevalent more in the younger generation of nurses, which is slowly becoming the majority in the workforce (Barbe et al., 2018). Some of the instruments found most acceptable by nurses to ensure safety include prevention more so than physical protection. Barbe et al. (2018) report that nurses prefer to know that the chances of a violent encounter are slim rather than worry about being attacked at any moment, even if security ensures their safety. These findings are supported by Temkin-Greener, Cen, and Li, (2020) who have uncovered that the establishment of a strong safety culture plays an important role in preventing turnover, with the majority of respondents answering the question with 4 or 5 on Likert scale.

Finally, the issue of 12-hour shifts versus 8-hour shifts has been explored by Banakhar (2017), who states that 12-hour shifts are preferred by older employees, whereas flexible shifts or 8-hour shifts fit newer employees better. The research speculates that the preference towards 12-hour shifts among the older generations appears as a result of a force of habit, whereas 8-hour shifts have better results when it comes to nurse retention, burnout, care fatigue, and performance (Banakhar, 2017). Overall, the article supports the proposed interventions, highlighting that temporary increases in expenditures for new personnel may be compensated long-term by achieving better HCAHPS scores, reducing recruitment expenditures, and decreasing the number of medical errors and rehospitalizations (Banakhar, 2017).

Plan of Action

The proposed project will have 5 stages, which include the preparation stage, three implementation stages, and a revision stage, during which the results will be assessed, and changes made (if any are necessary). The preparation stage will involve developing a detailed project plan, its presentation to AMRTC, and revisions made based on the primary stakeholders (excluding patients) notes and recommendations. During this stage, implementation of the project will be tailored to what resources and employees the hospital actually has. Meetings with hospital staff, hospital administration, and nurse leaders would be the primary method of interaction between the researchers and the participants.

The three implementation steps within the scope of this intervention would include the implementation of color-codes to illustrate the likelihood of patient violence as well as the restructuring of the existing scheduling to ensure that new nurses do not get to work with violent patients straight away, instead being given only green patients to work with. Yellow and red patients would be the primary responsibility of older and more experienced nurses, which would help avoid accidents. The second implementation step would be launched once the primary step achieves a tangible financial impact through reducing retention. It will be a largely administrative matter that would include the redistribution of the available recruitment funds towards nurses already on the job. The third step would be launched once the majority of vacancies in AMRTC are covered, and will involve a gradual change from a 12-hour to 8-hour shift pattern. This will be a practical and administrative matter, and would at first be conducted on a voluntary basis.

The last stage would involve the observation of the new model, with changes being made to the existing model of implementation if needed. All changes would first be discussed with hospital staff and the specially-appointed committee, before being implemented. These meetings would also be held on a semi-regular basis during the implementation stages, to make small alterations to the program should glaring issues be discovered in that stage.

Timeline

Due to the limitations of the project (organization’s timeline, terms), the proposed timeline will only encompass the first stage of the project, that being the preparation stage. It is as follows:

• Week 1: Development of the larger proposal to be presented to AMRTC.
• Week 2: Presentation of the proposed solution to hospital authorities in a series of meetings with the administration as well as nurse leaders.
• Week 3: Working with the hospital to adjust the proposal to the realities of the hospital in terms of systems, personnel, and materials available.
• Week 4-6: Preparation of all nurses, administrators, and healthcare managers in the facility for the implementation of the proposed solutions. These will include installing a color-code scheme and the familiarization of personnel with it as well as estimated projections for employee retention, financial retention, and scheduling changes to ensure that all new nurses would be assigned to green patients only.

Required Resources and Personnel

The intervention requires resources and personnel that would either be available at the start of the intervention or acquired during its implementation. For the preparation part, the resources would require the following: a meeting room, to conduct meetings with hospital staff, presentation equipment to demonstrate the benefits of the proposed solutions, a personal computer (or a laptop) to hold and process the information required for the intervention, as well as finances to accommodate travel and office expenditures for the duration. Personnel needs will be covered by the student, though the participation of hospital administrators and nursing leaders would be required as well. The roles of all participants would be distributed as follows:

• Student: Initiator of the project, negotiator and coordinator with administrative staff;
• Administrative staff: Primary coordinators and editors of the initial plan, their role includes facilitating the proposed changes and organizing nurses for its implementation;
• Nursing staff: Main implementers of the proposed project. May also provide suggestions for change during the practical phase.

Proposed Change Theory

The proposed change theory to facilitate the solutions mentioned in this paper is Kurt Lewin’s Freeze-Unfreeze model. It is a very popular theory that many nurse specialists are familiar with, and it is easy to utilize in the scope of this project (Burnes & Bargal, 2017). According to it, there are three distinct phases that must occur in a lasting planned change: Unfreezing, Change, and Freezing (Burnes & Bargal, 2017). The Unfreezing stage will occur during the preparation part of the plan, when nurses and administrators will be presented with the proposal and allow for its discussion. Change phase will occur during the three-step plan, which will seek to improve safety, compensation, and scheduling in AMRTC. Finally, after changes have been completed, a period will be dedicated to small alterations and re-freezing of the new model of operation as status quo.

Barriers to Implementation

Identified barriers to implementation of the proposed solutions is as follows:

• The chosen hospital may reject the proposal due to fundamental disagreements regarding the implementation and financing of the project;
• It would be impossible to allocate new nurses to green patients only without creating a disbalance;
• Retention and growth rates estimated in this paper would be below required;
• Money savings would be too low to enable significant salary raises.

In order to overcome these barriers, the researcher must be persuasive in their

presentation to hospital staff and operate using evidence-based practice. Alterations to the proposed solutions may be made to better reflect the situation on the ground. While retention and growth rates might be lower than projected, all evidence points to the presence of growth, meaning that certain stages would simply need more time to generate the needed effect. Same goes for economic gains, which may not be as soon as anticipated, but certain.

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