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"Fire any manager who invents a new form" was one of the written responses to a survey of nurses conducted by the Bernard Hodes Group, a human resources company based in New York City. (For a copy of the full survey, go to www.hodes.com/hcrecruiting.) Unfortunately for home health, a seemingly uncontrolled proliferation of new forms and additional paperwork creates one of the greatest obstacles to recruiting experienced nurses to home health, say experts.
While there are many positive aspects of home health nursing that help in recruitment, the increasing paperwork required by regulatory and reimbursement organizations is detrimental, says Coleen Conway-Svec, RN, MS, MBA, chief operating officer of the Visiting Nurse Association of Southeast Michigan in Oak Park. "Home health agencies have a better product to offer nurses than hospitals because we can offer positions that require independent decision making, flexible schedules, and an opportunity to develop a relationship with a patient," she says. "Unfortunately, the amount and detail of the paperwork required chases nurses away."
"One of our top priorities is to use technology to diminish the paperwork burden on our nurses," says Don Richardson, vice president of administration for the Visiting Nurse Association (VNA) of Texas in Dallas. "We are not automated at this time, but we are looking at automation of all of our forms," he says. "We are in a very competitive environment, with hospitals being our primary competition for nurses."
Hospitals tend to be Richardson’s biggest competitors for experienced nurses because the VNA of Texas pays registered nurses a salary rather than based on visits, he says. "Other home health agencies in the area pay based on visits, so a nurse that wants to go into home health finds our agency’s pay policy more attractive," he adds. "Unfortunately, this also means that the home health agency has to deal with local hospitals’ escalating salaries in order to compete."
Salary and benefits are not an issue for Conway-Svec’s agency, but she has had to address other issues to reach her goal of being fully staffed with RNs and having a few extra on board to handle growth, she says. "We have addressed the paperwork issue with all full-time field nurses having laptops," she points out. "They are able to complete the OASIS [Outcome and Assessment Information Set] forms and transmit them directly to the office without having to use paper."
The VNA of Southeast Michigan has not always enjoyed a full nursing staff. "Less than two years ago, we typically had a 30% vacancy rate, with tenure for new hires averaging six months," Conway-Svec points out. Even with the use of technology to automate paperwork, one of the most frequently cited reasons for nurses leaving after such a short time was that they didn’t realize how much documentation was required, she says.
"We realized that we weren’t painting a good picture of the job during the interview and hiring process," she explains. This realization led to the development of a new way to interview qualified applicants that enables the job applicant to see what is entailed in home health nursing while also giving the agency a chance to more fully evaluate the applicant’s qualifications for home health.
"Our applicant shadowing program allows a job applicant to spend half of a day with a field nurse making visits," explains Conway-Svec. "We pay the applicant to spend about four hours with one of our more experienced nurses, riding with the nurse to see patients," she says. While the job applicant doesn’t participate in provision of care, he or she does see the type of care, education, and documentation required during a home health visit, she adds. Not only does the applicant get an accurate impression of what home health is, but the field nurse has the opportunity to answer questions that may occur to the applicant after seeing a visit, she says. "The field nurse also has a chance to form an opinion of how well-suited the applicant may be to home health," she adds.
Address feelings of isolation
While use of laptop computers has made the nurse’s job more efficient and has reduced the driving required to come into the office to pick up visit schedules and turn in paperwork, the technology also has increased the feeling of isolation, another risk to retention of home health nurses, especially new hires, Conway-Svec notes.
Although the independence and autonomy of home health visits appeals to nurses who enjoy making decisions and working on their own, the technology that has removed the need to go into the office also has increased the isolation a field nurse may feel, she says. "We didn’t consider how this isolation would affect the team spirit of our staff when we began using laptops."
To address the lack of face-to-face time, Conway-Svec’s agency has developed a more structured continuing education program in which nurses must come to monthly courses. "We build time into each of these programs for networking, visiting with peers or managers, and sharing information or concerns," she adds. Managers and supervisors also stay in contact with staff members by voice mail or e-mail so questions can be answered quickly and concerns identified before the nurse is overwhelmed, she explains.
Once you’ve addressed your agency’s paperwork, salary, or isolation issues, it’s important to make sure you use the right techniques to attract nurses, Richardson adds. "We go through cycles when we are short-handed and need to recruit heavily, and then other times, we are fully staffed."
Depending on the agency’s need for staff, he uses a combination of print advertisements in newspapers or other periodicals, on-line recruitment, job fairs, direct mail, and referral bonuses for current employees.
Another key to identifying problems in recruitment or hiring is the exit interview, Richardson points out. While most agencies do conduct exit interviews, Richardson handles some employees’ exit interviews a little differently than normal. "Sometimes an employee is angry when they are leaving and their emotions may not enable them to give you an accurate explanation of the reasons for their leaving," he says. For this reason, he waits a month or two, then mails a written survey that asks them to give their opinion of the agency and explain their decision to leave. This cooling-off period results in a truer evaluation of the agency and more opportunities for improvement, he adds.
Perhaps the most important thing an agency can do to make sure recruitment and interviewing practices are resulting in the best hires is to track vacancy rates each month, suggests Conway-Svec. "I came to home health from hospital nursing administration, where we always thought in terms of full-time equivalents [FTEs] and noted open positions more easily. Because our agency pays on a per-visit basis, there is less emphasis on FTEs," she explains. As long as visits are made, it is hard to see potential problems with a shortage of staff.
To make sure managers and supervisors stay on top of keeping positions filled, the agency runs a monthly report that lists vacancies and the length of time it takes to fill them, Conway-Svec says. "If we can see trends that indicate a problem with our recruitment practices or problems in retaining new hires, we can look for solutions."