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Does your ED have high turnover and vacancy rates? You may be losing ED staff members to the competition because you’re not keeping up with trends in benefits, salary, and incentives, warns Nancy Bonalumi, RN, MS, CEN, director of emergency services for PinnacleHealth Hospitals in Harrisburg, PA. "With a nursing shortage, you need to find ways to keep the employees you have by being competitive in the market," she urges.
Current estimates show a vacancy rate of about 13% nationwide for nurses, reports George D. Velianoff, RN, DNS, CHE, executive vice president of nursing for the Des Plaines, IL-based Emergency Nurses Association. "That is not super high, but there is no one to fill the slots," he explains. "In the ED it is even more of a problem, because of having to hold patients that are admitted. There are no staff in the rest of the hospital to man the beds."
Here are current trends you’ll need to address in your ED:
• There is a narrow difference between staff and manager salary.
This trend is due to the highly competitive job market for staff nurses, says Bonalumi. Staff members receive incentives and bonuses that provide a take-home pay greater than a manager, and that can be frustrating to the manager, she explains. "We gave all our nurses, up to and including nurse managers, a $1 market adjustment in addition to their regular salary increase this July," reports Bonalumi. "There is nothing worse than to lose a good employee for a dollar an hour wage difference."
Staff appreciated the additional raise, she notes. "It made them feel respected and recognized, that the organization really did care about them and wanted to make them happy. Despite the fact that money is only a short-term satisfier in the workplace, it has helped morale here quite a bit."
• Generous relocation monies are being offered.
Bonalumi points to a new benefit being offered to nurses who have taken a position from another location: relocation money. "We offer relocation to staff nurses as well as managers, for employment at the acute-care hospitals," she says. "This is not offered at our specialty psychiatric and long-term care sites and not for our own physician practices." Nurses are offered between $2,000 and $5,000 in location support, depending on the position and how far away they are coming from, she says. "It is not the first time we offered relocation dollars, but we are more generous now than in the past because of the shortage," she adds.
• Incentives are being given for certain shifts.
Staff salary trends include incentive bonuses for working during high acuity, high vacancy, and less desirable shifts, and a differential for working in the ED, says Bonalumi. Some facilities are considering radical shift differentials, such as $5 to $10 per hour, for off-shifts and weekends, she reports. Pinnacle does not offer the radical shift differential, Bonalumi notes. "We had to make a choice about how we were going to spend our money and chose acuity and certification bonuses instead," she says.
Any nurse who works extra time on a unit with greater than a 20% vacancy rate is eligible for the vacancy bonus of $6-10 per hour, depending on the day and the shift, says Bonalumi. "Acuity bonus offers the same pay," she adds. "All these incentives are an attempt to improve staffing levels."
• Recruitment sign-on bonuses have created morale problems.
One concern with offering recruitment sign-on bonuses is the dissatisfaction it creates among current nursing staff, says Bonalumi. "This is especially true if you offer no additional incentives for that group," she adds. Sign-on bonuses can be a short-term fix, but may have a negative impact on morale for the long term, says Bonalumi. "Nurses feel devalued as long-term employees when an organization spends thousands on bringing in new staff, yet offers nothing to those who are experienced and have chosen to stay," she explains. Pinnacle does not offer nurses a sign-on bonus for this reason, she says.
• Certification bonuses are being given.
At Pinnacle, ED nurses are given annual certification bonuses of $500 annually, pro-rated for part-time employees. "We are offering this as a retention incentive," says Bonalumi. "Many of our senior staff are certified, and it is a way to recognize them for their expertise." Certification bonuses are also a good recruitment tool if a new nurse is certified upon hire, she says. "They are eligible after successfully completing their six-month probationary period," she explains.
ED nurse managers are leaving positions for a variety of reasons, according to Diana Contino, RN, MBA, CEN, CCRN, president of Emergency Management Systems, a Monarch Beach, CA-based consulting firm that specializes in staffing issues. These reasons include lack of support from administrators, lack of training regarding business operations, inability to implement solutions to fix the problems, lack of decision-making autonomy to solve problems, and frustration with staffing shortages, she says.
In many facilities, the nurse manager is still seen as the staffing coordinator, says Contino. "We need to elevate the role of the nurse manager and enhance the education requirements and accountability," she argues. If you have high manager turnover at your ED, you probably have unrealistic expectations and lack a defined role for the position, Contino says.
Nurse managers have to focus continually on decreasing expenses by cutting staffing costs and increasing efficiencies, she says. "Often, this is a no-win situation and professionally unrewarding." A key part of the nurse manager role is support of ED staff, she emphasizes. "Today’s nurse manager needs experience and education in managing human resources, decreasing turnover, and finding creative ways to make nurses feel valued and important so they will stay," she says.
Contino points to a trend of hiring nurse managers with MBAs. "Some facilities are hiring business managers. These are non-nurses with MBAs," she adds. Nurse managers "absolutely need to understand" the financial operations of the hospital, she underscores. "They must be able to translate workflow into cash flow," she says. You must be able to do a cost/benefit analysis of projects, she explains. "Successful managers meet budgets, enhance quality, implement creative solutions, and decrease turnover," she says.
The ED Management 2001 Salary Survey was mailed in June to 1,453 subscribers. There were 128 responses, for a response rate of 8.8%. Here are several career and salary trends for ED managers, based on the survey results:
• Salaries have increased somewhat.
According to the survey, 91% of ED managers make at least $50,000 per year, with 63% of total respondents reporting an increase of 1% to 6% over the last year. Salary trends depend largely upon the hospital’s financial status, explains Contino. "Facilities that are breaking even and or have profits of 1% to 3% have the ability to increase the employer contributions to 401Ks, increase vacation time, increase reimbursement for education and or increase sign-on or retention bonuses," she says. (For more on benefits, see "Which benefits are important to you?" in this issue.)
Other facilities are changing their reimbursement structures to increase the salaries for higher degrees and specialty certifications, says Contino. The hospitals that are losing money have fewer options, she notes. "They are hoping for more new graduates, because they are unable to increase salaries or benefits," she says. "They are scrambling for ways to cut costs so they can cover their agency expense." Many of these facilities are changing staffing patterns to utilize more unlicensed staff, she adds.
• Most ED managers work more than 46 hours a week.
The survey’s results showed that 82% of respondents work more than 46 hours a week, and almost half work more than 50 hours a week. As an ED manager, you’ll need to find ways to meet a variety of different staff needs, including decreasing the workload if needed, says Contino. "Today’s nurse manager has to blend many solutions to meet the multiple needs of today’s nursing workforce," she emphasizes.
According to the survey, 78% of ED managers responded that a flexible work schedule was important or very important. "For some employees, scheduling may be the most important thing. For others, benefits, education, or money may be the No. 1 priority," she adds. "The successful manager knows who is who and finds creative ways to meet their needs."
Contino gives the following example: A 20-year-old nurse who is just out of school might be willing to work more overtime. In return for picking up extra shifts when needed, the nurse may want to arrange several days off in a row, she says. Another nurse may want to go back to school and is considering working for a registry instead of the ED, Contino says. "See if you can offer a retention bonus and significant education reimbursement to keep the nurse from leaving,’ she recommends.
Similarly, a single nurse may pay close attention to retirement and health benefits. "Know how to sell these benefits for your institution," she says. "If your facility doesn’t have a 401K with matching funds, then suggest that they get one as a recruiting tool."
• Staff size has increased in the past year.
According to the survey, 58% of ED managers have seen the number of employees in their department grow in the past year. "I’m finding facilities are adding staff to the ED, many of which were understaffed," says Contino. "If you look at the staffing benchmarks used by the consulting firms, many were unrealistic for the ED," she adds. This is a major reason for the current staffing shortages in many EDs, Contino concludes. "Nurses do not want to work in unsafe, understaffed environments," she says.