Additional Learning Exercises and Applications
DISPLAY 15.2 Leadership Roles and Management Functions Associated With
Preliminary Staffing Functions
Leadership Roles
1. Is knowledgeable regarding current and historical staffing variables 2. Identifies and recruits talented people to the organization
3. Encourages and seeks diversity in staffing
4. Is self-aware regarding personal biases during the preemployment process
5. Seeks to find the best possible fit between employees’ unique talents and organizational staffing needs 6. Reviews induction and orientation programs periodically to ascertain they are meeting unit needs 7. Ensures that each new employee understands appropriate organizational policies
8. Aspires continually to create a work environment that promotes retention and worker satisfaction 9. Promotes hiring based on preferred criteria rather than minimum criteria
Management Functions
1. Plans for future staffing needs proactively to ensure an adequate skilled workforce to meet the goals of the organization
2. Shares responsibility for the recruitment of staff with organization recruiters 3. Plans and structures appropriate interview activities
4. Uses techniques that increase the validity and reliability of the interview process
5. Applies knowledge of the legal requirements of interviewing and selection to ensure that the organization is not unfair in its hiring practices
6. Develops established criteria for employment selection purposes
7. Uses knowledge of organizational needs and employee strengths to make placement decisions 8. Interprets information in employee handbook and provides input for handbook revisions 9. Participates actively in employee orientation
Predicting Staffing Needs
Accurately predicting staffing needs is a crucial management skill because it enables the manager to avoid staffing crises. Managers should know the source of their nursing pool, the number of students enrolled in local nursing schools, the usual length of employment of newly hired staff, peak staff resignation periods, and times when the patient census is highest. In addition, managers must consider the patient care delivery system in place, the education and knowledge level of needed staff, budget constraints, historical staffing needs and availability, and the diversity of the patient population to be served.
Managers also need to have a fairly sophisticated understanding of third-party insurer reimbursement because this has a significant impact on staffing in contemporary health-care organizations. For example, as government and private insurer reimbursements declined in the 1990s, many health-care organizations—
hospitals in particular—began downsizing by replacing registered nurse (RN) positions with unlicensed assistive personnel. Even hospitals that did not downsize during this period often did little to recruit qualified RNs. This downsizing and shortsightedness regarding recruitment and retention contributed to an acute shortage of RNs in many health-care settings in the late 1990s.
Hospital downsizing and shortsightedness regarding recruitment and retention contributed to the beginning of an acute shortage of RNs in many health-care settings by the late 1990s.
The health-care quality and safety movement also exacerbated this shortage in the late 1990s as research emerged to demonstrate the relationship between nurse staffing and patient outcomes and the public became aware of how important an adequately sized workforce was to patient safety.
The manager also should be aware of the role that national and local economics play in staffing.
Historically, nursing shortages occur when the economy is on the upswing and decline when the economy
recedes because many unemployed nurses return to the workforce and part-time employees return to full-time employment. This is only a guideline, however, as some workforce shortages have occurred regardless of the economic climate. There is little doubt, however, that predicted recent shortages would have been worse, had the economic downturn not occurred, because the recession caused many part-time nurses to return to full- time employment and others to delay their retirement.
Historically, when the economy improves, nursing shortages occur. When the economy declines, nursing vacancy rates decline as well.
Is a Nursing Shortage Imminent?
Health-care managers have long been sensitive to the importance of physical (technology and space) and financial resources to the success of service delivery. It is the shortage of human resources, however, that likely poses the greatest challenge to most health-care organizations today. Many experts suggested at the close of the first decade of the 21st century that the United States would be facing a profound nursing shortage by 2020.
Economists suggest, however, that as a result of the recent recession, many nurses who planned to retire put off their retirements; many nurses who were working part time increased their employment to full time; and some nurses who had been out of the profession for 5 years or more returned to the workforce. Economists call the situation a nursing employment bubble and warn that if the economy were to dramatically improve and nurses were to suddenly retire or reduce their work hours, that a significant nursing shortage could emerge literally overnight.
The recent economic crisis obscured whether a nursing shortage exists.
The current situation, however, is that although the recession appears to have improved, nurses are still hanging on to their jobs and consumer confidence is slow to return. Thus, the extent of any projected shortage is hard to determine. The American Association of Colleges of Nursing (AACN, 2016) concurs, arguing that given the fluctuations in the economy, it is difficult to “accurately project how long the nation will take to recover and exactly when old workforce patterns may re-emerge. In the short term, the changing
characteristics of employment options for new nurses are causing frustration to many new graduates who expected a different occupational outlook from what currently exists in many places” (para. 10). To more accurately assess the depth or significance of any projected nursing shortage then, data must be examined regarding both the demand for RNs and the supply.
Supply and Demand Factors Leading to a Potential Nursing Shortage
Demand
Demand for RNs is expected to continue or accelerate. As of 2014, the United States had about 3 million RNs filling about 2.8 million jobs; about 1 out of 6 RNs worked part time (Bureau of Labor Statistics, 2015b).
Despite declining vacancy rates, particularly at hospitals, this does not appear to be enough to meet either short- or long-term needs in hospitals or other health-care settings.
According to the Bureau of Labor Statistics’ (2015a) employment projections 2014–2024 released in December 2015, registered nursing is listed among the top occupations in terms of job growth through 2024.
Indeed, employment of RNs is projected to grow 16% from 2014 to 2024, much faster than the average for all occupations.
Growth will occur for a number of reasons. The RN workforce is expected to grow from 2.75 million in 2014 to 3.19 million in 2024, an increase of 493,300 or 16% (Bureau of Labor Statistics, 2015a). Similarly, AACN (2014) notes that according to the 2012 “United States Registered Nurse Workforce Report Card and Shortage Forecast,” a shortage of RNs is projected to spread across the country between 2009 and 2030, with
the shortage being felt most intensely in the Southern and Western United States.
Demand for RNs will also be driven by technological advances in patient care and by the increasing emphasis on preventive health care. In addition, a growing elderly population with extended longevity and more chronic health conditions requires more nursing care. Huston (2017b) notes that as life expectancy in the United States increases, more nurses will be needed to assist the individuals who are surviving serious
illnesses and living longer with chronic diseases. The AACN (2014) concurs, suggesting that as baby boomers enter their retirement years, their demand for care is escalating and health-care reform will soon provide subsidies for more than 30 million citizens to more fully use the health-care system. As a result, the demand for health care is expected to steadily increase in the next few decades, and the numbers of nurses to care for these patients will lag behind.
Supply
Huston (2017b) notes that enrollment in nursing schools has steadily increased every year for almost a decade.
Unfortunately, however, these increases are not adequate to replace those nurses who will be lost to retirement in the coming decade. Ironically, recruitment efforts into the nursing profession in the last decade have been very successful, and the problem is no longer a lack of nursing school applicants. Indeed, enrollment in nursing programs of education has increased steadily since 2001. The problem is that there are inadequate resources to provide nursing education to those interested in pursuing nursing as a career, including an insufficient number of clinical sites, classroom space, nursing faculty, and clinical preceptors. As a result, qualified applicants are turned away, despite the current shortage of nurses. Indeed, the AACN (2015) reported that 68,938 qualified applicants were turned away from baccalaureate and graduate nursing programs alone in 2014.
Almost two thirds of the nursing schools responding to the survey pointed to faculty shortages as a reason for not accepting all qualified applicants into their programs (AACN, 2015). According to a Special Survey on Vacant Faculty Positions released by AACN in October 2014, a total of 1,236 faculty vacancies were identified in a survey of 714 nursing schools with baccalaureate and/or graduate programs across the country, creating a national nurse faculty vacancy rate of 6.9% (AACN, 2015). The top reasons cited by schools having difficulty finding faculty were limited funds to hire new faculty, a limited number of doctorally prepared faculty, and noncompetitive salaries compared with positions in the practice arena (AACN, 2015).
One must question where the faculty will come from to teach the new nurses who will be needed to address nursing shortages in the coming decade. Nursing faculty salaries have failed to keep pace with that of nurses employed in clinical settings, making it difficult to attract and keep graduate and doctorally prepared nurses in academic settings. Clearly then, given the lag time required to educate master’s- or doctorally prepared faculty, the faculty shortage may end up being the greatest obstacle to solving the nursing shortage (Huston, 2017b).
The nursing faculty shortage may well be the greatest obstacle to solving the projected nursing shortage.
In addition, Huston (2017b) notes that nursing is a graying population—even more so than the population at large. This means that the nursing workforce is retiring at a rate faster than it can be replaced. According to a 2013 survey conducted by the National Council of State Boards of Nursing and the Forum of State Nursing Workforce Centers, 55% of the RN workforce is age 50 years or older (AACN, 2014). In addition, the Health Resources and Services Administration projects that more than 1 million RNs will reach retirement age within the next 10 to 15 years (AACN, 2014).
The bottom line is that the supply of RNs is expected to grow minimally in the coming decade, but large numbers of nurses are expected to retire. It must be noted, however, that despite evidence projecting a significant shortage, new nurse graduates in many parts of the country continue to report having difficulty finding jobs, particularly in hospital settings. Why is this occurring? In some cases, it reflected skittishness on the part of health-care organizations to take on new staff during an economic downturn, particularly
inexperienced ones who may need prolonged orientation and training. Instead, health-care organizations are
seeking to hire experienced nurses, with specialty certifications in hand, who can assume full patient loads upon hire. One must at least question, however, whether this is shortsighted because it is likely that these organizations will be desperate to hire these same graduates in a few short years when the economy improves and large groups of nurses once again exit the workforce or reduce their working hours.
In addition, Magnet hospitals prefer to hire baccalaureate graduates, making it more difficult for nurses educated in diploma or associate degree programs to find jobs. The 2010 Institute of Medicine (IOM) report, The Future of Nursing, recommended a rapid escalation of baccalaureate degree completion for RNs, and this, too, will further job-hunting challenges for newly graduated associate degree and diploma-educated nurses in the coming decade.
Recruitment
Recruitment is the process of actively seeking out or attracting applicants for existing positions and should be an ongoing process. In complex organizations, work must be accomplished by groups of people; therefore, the organization’s ability to meet its goals and objectives relates directly to the quality of its employees.
Unfortunately, some managers feel threatened by bright and talented people and surround themselves with mediocrity. Wise leader-managers surround themselves with people of ability, motivation, and promise.
In addition, organizations must remember that nonmonetary factors are just as important, if not more so, in recruiting new employees. Before recruiting begins, organizations must identify reasons a prospective employee would choose to work for them over a competitor. Organizations considered best places to work typically are financially sustainable and focused on quality.
The Nurse-Recruiter
The manager may be greatly or minimally involved with recruiting, interviewing, and selecting personnel depending on (a) the size of the institution, (b) the existence of a separate personnel department, (c) the presence of a nurse-recruiter within the organization, and (d) the use of centralized or decentralized nursing management.
Generally speaking, the more decentralized nursing management and the less complex the personnel department is, the greater the involvement of lower level managers in selecting personnel for individual units or departments. When deciding whether to hire a nurse-recruiter or decentralize the responsibility for recruitment, the organization needs to weigh benefits against costs. Costs include more than financial considerations. For example, an additional cost to an organization employing a nurse-recruiter might be the eventual loss of interest by managers in the recruiting process. The organization loses if managers relegate their collective and individual responsibilities to the nurse-recruiter.
When organizations use nurse-recruiters, a collaborative relationship must exist between managers and recruiters. Managers must be aware of recruitment constraints, and the recruiter must be aware of individual department needs and culture. Both parties must understand the organization’s philosophy, benefit programs, salary scale, and other factors that influence employee retention.
The Relationship Between Recruitment and Retention
Recruiting adequate numbers of nurses is less difficult if the organization is located in a progressive community with several schools of nursing and if the organization has a good reputation for quality patient care and fair employment practices. It will likely be much more difficult to recruit nurses to rural areas that historically have experienced less appropriation of health-care professionals per capita than urban areas. In addition, some health-care organizations find it necessary to do external recruitment, partly because of their lack of attention to retention.
Because most recruitment is expensive, health-care organizations often seek less costly means to achieve this goal. One of the best ways to maintain an adequate employee pool is by word of mouth; the
recommendation of the organization’s own satisfied and happy staff. A 2013 Gallup poll found that work groups with high employee engagement have a 65% lower turnover rate than those with low engagement (Saver, 2015). Higher engaged work groups also had 22% higher profitability and 21% higher productivity.
Unfortunately, only 31.5% of US employees are engaged (Saver, 2015).
Recruitment, however, is not the key to adequate staffing in the long term—retention is, and it only occurs when the organization is able to create a work environment that makes staff want to stay. Such environments have been called healthy work environments. The American Nurses Association (ANA, 2016) suggests “a healthy work environment is one that is safe, empowering, and satisfying” (para. 1). In healthy work environments, “all leaders, managers, health care workers, and ancillary staff have a responsibility as part of the patient centered team to perform with a sense of professionalism, accountability, transparency,
involvement, efficiency, and effectiveness. All must be mindful of the health and safety for both the patient and the health care worker in any setting providing health care, providing a sense of safety, respect, and empowerment to and for all persons” (ANA, 2016, para. 1).
Some turnover, however, is normal and, in fact, desirable. Turnover infuses the organization with fresh ideas. It also reduces the probability of groupthink in which everyone shares similar thought processes, values, and goals. However, excessive or unnecessary turnover reduces the ability of the organization to produce its end product and is expensive. Such costs generally include human resource expenses for advertising and interviewing; recruitment fees such as sign-on bonuses; increased use of traveling nurses, overtime, and temporary replacements for the lost worker; lost productivity; and the costs of training time to bring the new employee up to desired efficiency.
Indeed, the replacement cost for an RN typically ranges from $36,000 to $64,000. In a small organization with 150 nurses and a 25% turnover rate, the cost of turnover would be $1.125 million per year (Morgeson, 2015). Even small decreases in turnover then can result in big savings. For example, for every 1% reduction in turnover, the same facility noted above could save $300,000 per year.
The leader-manager recognizes the link between retention and recruitment. The middle-level manager often has the greatest impact in creating a positive social climate to promote retention. In addition, the closer the fit between what the nurse is seeking in employment and what the organization can offer, the greater the chance that the nurse will be retained.
LEARNING EXERCISE
15.1
Examining Recruitment Advertisements
S
elect one of the following:1. In small groups, examine several nursing journals that carry job advertisements. Select three
advertisements that particularly appeal to you. What do these advertisements say or what makes them stand out? Are similar key words used in all three advertisements? What bonuses or incentives are being offered to attract qualified professional nurses?
2. Select a health-care agency in your area. Write an advertisement or recruitment poster that accurately depicts the agency and the community. Compare your completed advertisement or recruitment flyer with those created by others in your group.
Interviewing as a Selection Tool
An interview may be defined as a verbal interaction between individuals for a particular purpose. Although other tools such as testing and reference checks may be used, the interview is frequently accepted as the foundation for hiring, despite its well-known limitations in terms of reliability and validity.
The purposes or goals of the selection interview are threefold: (a) the interviewer seeks to obtain enough information to determine the applicant’s suitability for the available position; (b) the applicant obtains adequate information to make an intelligent decision about accepting the job, should it be offered; and (c) the interviewer seeks to conduct the interview in such a manner that regardless of the interview’s result, the applicant will continue to have respect for and goodwill toward the organization.
There are many types of interviews and formats for conducting them. For example, interviews may be
unstructured, semistructured, or structured. The unstructured interview requires little planning because the goals for hiring may be unclear, questions are not prepared in advance, and often, the interviewer does more talking than the applicant. The unstructured interview continues to be the most common selection tool in use today.
Semistructured interviews require some planning because the flow is focused and directed at major topic areas, although there is flexibility in the approach. The structured interview requires greater planning time, yet because questions must be developed in advance that address the specific job requirements, information must be offered about the skills and qualities being sought, examples of the applicant’s experience must be
received, and the willingness or motivation of the applicant to do the job must be determined. The interviewer who uses a structured format would ask the same essential questions of all applicants.
Limitations of Interviews
The major defect of the hiring interview is subjectivity. Accel-Team (2015) notes that the interview as a selection tool is regarded by some as being so subjective as to be totally worthless. Others maintain that they can tell as soon as a candidate has walked through the door of the interview room, whether the person is suitable or not. “Such interviewers, with implicit faith in their own judgement, tend to assume that their own highly personalized methods are the right answer to their (and everyone else) problems” (Accel-Team, 2015, para. 5–6).
Many people think they are better interviewers than they really are.
Indeed, research findings regarding the validity and reliability of interviews vary; however, the following findings are generally accepted:
The same interviewer will consistently rate the interviewee the same. Therefore, the intrarater reliability is said to be high.
If two different interviewers conduct unstructured interviews of the same applicant, their ratings will not be consistent. Therefore, interrater reliability is extremely low in unstructured interviews.
Interrater reliability is better if the interview is structured and the same format is used by both interviewers.
Even if the interview has reliability (i.e., it measures the same thing consistently), it still may not be valid. Validity occurs when the interview measures what it is supposed to measure, which in this case, is the potential for productivity as an employee. Structured interviews have greater validity than
unstructured interviews and thus should be better predictor of job performance and overall effectiveness than unstructured interviews.
High interview assessments are not related to subsequent high-level job performance.
Validity increases when there is a team approach to the interview.
The attitudes and biases of interviewers greatly influence how candidates are rated. Although steps can be taken to reduce subjectivity, it cannot be eliminated entirely.
The interviewer is more influenced by unfavorable information than by favorable information. Negative information is weighed more heavily than positive information about the applicant.
Interviewers tend to make up their minds about hiring applicants very early in the job interview.
Decisions are often formed in the first few minutes of the interview.
In unstructured interviews, the interviewer tends to do most of the talking, whereas in structured interviews, the interviewer talks less. The goal should always be to have the interviewee do most of the talking.
These confusing and sometimes contradictory findings recently led a research team to explore whether interviews were an appropriate selection tool for medical student admission to a residency placement (Stephenson-Famy et al., 2015). The researchers noted that although resident selection interviews have been criticized for their “dubious value” due to the lack of a standardized approach, low interrater reliability, and the potential for a significant “halo effect,” (interviewers’ have prior knowledge about an applicant’s academic grades and test scores), they are frequently used as a selection tool. Following an extensive review