1. Smith, Diane RN, CNO

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Because exceptional nursing care is an essential facet of healthcare services, staffing challenges within a nursing department present a significant problem that can dramatically affect a hospital's operations. Recently, Sierra Health Services, Las Vegas, Nev., decided to analyze a fresh methodology to meeting nursing shortage challenges by using long-range plans for recruitment and retention of skilled personnel. This six-pronged approach resulted in the successful recruitment of nurse apprentices for available positions, with early indications showing promise toward a positive impact on retention rates and return investment.


Six pillars of excellence

Although healthcare facilities in the area are expanding proportionately to meet the demand Nevada faces as the fastest growing state, nationwide factors impacting distribution and overall retention of the nursing work-force still exist. Despite the application of successful mentoring programs that include partnerships between service and academia to provide clinical training sites, nurse apprentice programs allowing employment of student nurses in the clinical setting, and orientation programs for graduate nurses, adequate retention continues to be an increasing problem.


To better understand retention issues, Sierra's nurse leader participated in a conference with the Nevada Organization of Nurse Leaders in spring 2002. This conference provided multiple approaches toward improved recruitment and retention techniques as seen from the management perspective. Additionally, participants reviewed a study completed by the Advisory Board Company that compiled survey responses from nurses employed at several hospital locations in both urban and rural settings. This ultimately revealed the foundational elements known as "the six pillars of excellence." These include:


1. Managed staff selection, as selecting well will mean a much greater chance that people will develop bonds over time.


2. Hardwired nurse-physician partnerships based on clear expression of expectations and zero tolerance of abusive behavior.


3. Implementing 360-degree recognition to forge bonds with employees to acknowledge staff contributions and performance.


4. Customized career sculpting to create a vision of professional growth and educational opportunities tailored to personal goals and needs.


5. Structured upward communication to instill a culture of responsiveness to employee input and foster trust between the staff and organization.


6. A nurse champion that assists in creating an environment for the pillars and leverages departmental and company activities to promote nursing growth. 1



The results of the report provided the catalyst for Sierra to explore long-term approaches for recruitment and the implementation of this six-pillar destination model in its ambulatory care setting.



Following the structure of the pillars model to manage staff selection, customize career sculpting, and structure upward communication, Sierra's nurse leader proposed new positions that opened the door for a nurse apprentice and nurse intern program. Whereas previous history dictated that employees graduating from nursing school weren't invited into the organization by nurse leader(s), this program promotes recruitment at the nursing school level and allows those in graduate status or newly licensed status to enter the organization through a program of support and learning. Students receive continued learning opportunities in skills achieved through their collegiate institution that range from roles providing basic care and minor procedures to case management activities.


Part of the gamble Sierra faced in introducing this program was whether its current nursing staff would welcome the novice nurses. On acceptance of the proposal, the program and general expectations of mentoring responsibility were introduced to the divisional leader(s) in the ambulatory care areas. To facilitate a positive environment, nurse mentors were selected from a pool of volunteers who successfully demonstrated expertise in their respective areas.


Minimizing risk

Another ongoing gamble was in the selection of appropriate candidates and spending time and money on students who may not graduate or not stay with the company after graduation. To be competitive in recruitment and have adequate prospects for selection, this program differs from regional hospital programs by not requiring the student to contract for a specific length of employment following completion of the program. The risk of nonretention is minimized by the presence of post-program hiring preferences and facilitative processes.


To increase student success, the program differs from hospital programs in that the student isn't included in the staffing. This allows for resources consistent with a positive learning environment. Moreover, the program differs in that it encourages the student to float to ambulatory areas to coincide with his/her nursing curriculum. Orientation and education of students regarding their limitations also serve to reduce the organizational risk in employing novice nurses.


To further minimize selection risk, interview questions derived from the American Nurses Association were incorporated into the interview. At the time of an initial interview with the professional administration staff, each candidate was required to submit a letter confirming his/her enrollment in a nursing program, current competencies completed and signed by the nursing instructor, and a letter of reference from a nursing instructor indicating the student's readiness for apprenticeship. The student then interviewed with a divisional director of nursing who would be his/her nurse leader before being offered a position.


Upon acceptance of the position, students completed the human resources hiring procedures including orientation and skills competency validation before starting on their respective units. The last gamble was allowing the new nurse apprentices to assist the nurse leader with the program's design and structure. "Solid walls" for the program included the Nevada regulatory requirements and the student's abilities in competency performance. "Fluid walls" allowed the student to construct the box for his/her own program with desire to learn new things, communicate with RN mentors, and communicate with providers while on a unit. Ultimately, this last gamble produced an outstanding first group of students.


Breaking cultural barriers

Although a small, convenience sample limits the results of this study, the positive approach to this long-range recruitment process has changed some of the cultural barriers for the student and novice nurse at Sierra. The program has created opportunities for clinical experience as well as employment options that weren't previously accessible. Nurses who took on the role of mentor were overwhelmingly positive about the experience. Of the original participating apprentices, half have indicated their intentions to stay with the company.


While the long-term realization of nurse retention is yet to be seen, an additional eight nurse apprenticeship program positions were approved and filled since the program's inception. The apprenticeship model now includes other professions found in Sierra's healthcare environment, such as social worker, pharmacist, advanced nurse practitioner, and physician assistant. In addition, a formal mentor-training program is under development to supplement the original mentor orientation. Further study regarding the impact of mentor programs, as well as other recruitment and retention strategies on nurse retention rates in the ambulatory setting, is warranted.




1. Meadows J. Destination Nursing: Creating a Destination Hospital for Nurses. Washington, DC: The Advisory Board Company; 2002. [Context Link]