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Recruitment Attributes Important to New Nurse Graduates Employed on Adult Medical-Surgical Units
Susan Steele-Moses Eileen Creel Ann Carruth
W orkforce data project a national shortage of 1 million nurses by 2025, with much of this occurring in med- ical-surgical nursing (U.S. Depart- ment of Health and Human Services, 2013). The aging registered nursing workforce is a major con- tributor (Hayward, Bungay, Wolff, & MacDonald, 2016), with one-third of nurses projected to retire by 2020 (Buerhaus, Auerbach, Staiger, & Muench, 2013). Recruitment and retention of medical-surgical nurses appear critical. As part of a larger study, the qualitative findings only are reported in this article.
Literature Review
Relevant literature for 2012-2017 was identified through a search of ProQuest, Medline, and CINAHL using the following key words: regis- tered nurse recruitment, nurse recruit- ment, and recruitment attributes. Of 13 identified articles, seven non- research articles were eliminated. Several elements were identified as important attributes for nursing recruitment and are described here.
Compensation
Although hospital administra- tors may believe money recruits nurses to their facilities, there is lim- ited research to support this posi- tion. In an electronic analysis of recruitment practices in Canada, Mathews and Ryan (2015) found financial incentives, such as salary, sign-on bonuses, and relocation expense reimbursement, were
Recruitment of registered nurses to a medical-surgical unit is often challenging. This study addresses attributes nurses consider when making decisions for employment on a medical-surgical unit.
viewed cautiously by the nursing workforce. While nurse turnover cost approximately one-half a nurse's salary to replace the position in a prospective quantitative study (N=156), the decision to leave a position rarely was based on salary (North et al., 2013). Thus, pay is not always a motivator.
Unit and Shift Preference
Unit and shift preference are cited in the literature as reasons nurse graduates select their first nursing positions, with specialty units often preferred (Mathews & Ryan, 2015; Phillips, Kenny, Esterman, & Smith, 2014; Pottinger, 2016). While nurse leaders may assume nurses prefer specialty units and day shift over other options, limited literature supports this belief. Pottinger (2016) conducted a pilot program to acclimate 12 nurse graduates to the intensive care set-
ting. While graduates worked rotat- ing shifts with a nurse preceptor to acclimate them to critical care nurs- ing, no one shift was cited as pre- ferred. A National Workforce analy- sis in Australia determined new nurses preferred to work in primary care based on shift consistency (Gordon et al., 2014). There was no consistent support for the percep- tion that nurses make initial employment decisions based on shift preference.
Nurse Orientation
Limited research has been pub- lished about hospital selection based on the availability of a resi- dency or prolonged orientation. To prepare for succession planning, Jones and co-authors (2017) used the "valuable expert knowledge and wisdom of retiring nurses" (p. 64) to facilitate new nurse orientation in a new graduate residency program.
Susan Steele-Moses, DNS, APRN-CNS, is Associate Professor and Dean, School of Health Professions, Franciscan Missionaries of Our Lady University, Baton Rouge, LA.
Eileen Creel, DNS, RN, is Associate Professor and Department Head, School of Nursing, Southeastern Louisiana University, Hammond, LA.
Ann Carruth, DNS, RN, is Professor and Dean, College of Nursing and Allied Health, Southeastern Louisiana University, Hammond, LA.
Note: This study was funded by the Louisiana State Board of Regents (HCWF-OLOLC- RECRUITMENT-FY16).
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Recruitment Attributes Important to New Nurse Graduates Employed on Adult Medical-Surgical Units
Background
Attributes inherent to a nurse's initial employment decision to work on a medical-surgical unit are not understood.
Purpose
Elucidate the factors new nurse graduates consider when making their first employment decisions.
Methods
Nurses from five acute care facilities participated. Results from the quan- titative survey, not reported here, were used to construct interview ques- tions to provide a deeper understanding of recruitment attributes.
Findings
Recruitment attributes inherently important to new nurses included a supportive manager, feeling valued, and work-life balance. While equi- table pay and benefits were important, nurses were more concerned with workload, scheduling, and the hospital's reputation.
Limitations and Implications
The sample was limited to five acute care facilities located in the South. Findings from this study supported transcendence to a transformational leadership style with a strong emphasis on work/life balance. Further, selecting staff who complement the nurses already in place is critical to creating a positive work relationship.
Conclusion
Position acceptance may be predicated on nurses' belief the manager cares about them.
This pilot project began with 17 nurse graduates. It combined tradi- tional orientation practices with simulation-based education. After the 12-week orientation, ongoing support continued for the first year of employment. New graduate nurse turnover decreased from 6.4% to 2% (n=1). In a secondary analysis of two qualitative data sets (eight focus group interviews [N=67]) and participant responses to open- ended questions from an electronic survey (N=392), Phillips and co- authors (2014) found nurse satisfac- tion resulted when new nurse ori- entation was thorough, sustained, and well organized. These authors also determined initial career place- ment on a specialty unit was beyond nurses' skill set and required prolonged orientation.
Hospital Reputation
In a slightly older study, positive word-of-mouth employment infor- mation received early in the recruit- ment process positively influenced the employment decision more than any other recruitment process (N=612; r2=0.396; p<0.01) (Van Hoye & Lievens, 2009). In a second- ary analysis by Phillips and associ- ates (2014), qualitative data from eight focus groups were analyzed to identify transitions that impacted new graduate transition. This study identified the importance of a sup- portive institutional environment that fostered mutual respect as well as a fair, equitable patient care assignment. Hayward and co- authors (2016) interviewed 12 med- ical-surgical registered nurses con- cerning factors related to turnover. Using a qualitative inductive ana- lytic approach, authors determined
nurse-patient ratio was a main rea- son nurses left their positions. Further, the work relationship with others and lack of leadership sup- port left them ill-equipped to per- form their jobs.
These studies were not conduct- ed with medical-surgical nurses, and findings were inconclusive and conflicting. Thus, the purpose of this study was to elucidate the attributes important to new nurse graduates when making the deci- sion to begin their careers on a medical-surgical unit.
Sample Selection
Of 20 nurses who volunteered to participate in the interviews, 10 scheduled an appointment. Two participants were African-American females, one an African-American male, one an Asian female, and one a White male; the remaining five nurses were White females (age range 23-59). Participants represent- ed five hospitals, worked on a med- ical-surgical unit, and had been nurses for no more than 1 year.
Ethics
The study was approved by Institutional Review Boards from Franciscan Missionaries of Our Lady University (study number 1527) and Southeastern Louisiana Uni- versity (study number 16-077). Interviews were conducted in a pri- vate conference room away from the nursing units. Written informed consent was obtained by the researcher from each nurse before the interview commenced, and only the investigator knew who participated.
Qualitative Framework, Design, and Methods
A descriptive qualitative frame- work was used for the second phase of the study, appropriate when no specific qualitative tradition is fol- lowed (Polit & Beck, 2014). Semi- structured interviews guided the data collection phase to allow flexi- bility and clarity during the inter- view process.
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Data Collection
Lunch was provided and each participant received a $25.00 hono- rarium at the completion of the interview. Interviews were audio- recorded, lasted approximately 1 hour, and were transcribed verba- tim. Anecdotal notes of the researcher's initial thoughts and impressions of the participant's demeanor were written following each interview. Saturation was achieved and no new themes emerged after 10 interviews were completed.
Data Analysis
Qualitative content analysis was used to analyze the data (Houser, 2015; Polit & Beck, 2014). As the semi-structured interview responses were transcribed, the primary re- searcher compared recorded inter- views with transcripts to ensure accuracy of wording and authentic representation of participants' words and experiences. Subsequently, three co-researchers independently read the transcripts to identify words or sentences that were espe- cially salient. Once identified, these words and sentences were analyzed for patterns and categories were named. Individual interviews were compared to the whole to analyze how each interview fit with the other, and how each interview fit within the whole.
Trustworthiness criteria were used to assure the rigor of data analysis (Lincoln & Guba, 1985). Credibility was addressed through careful review for accuracy of partic- ipant voice in verbatim transcrip- tions, completing data analysis tri- angulation with three researchers, and interviewing until data satura- tion was reached. Dependability and confirmability were ensured through a detailed audit trail outlin- ing each researcher's decisions and then consensus decisions about final themes. This audit (memo) kept during data analysis included notes on how themes were chosen, researchers' thoughts on themes, and alternative speculations. Thick, vivid description in participants' words were used to facilitate trans- ferability (Lincoln & Guba, 1985).
Results
Two main themes emerged from analysis of nurses' interviews: Get on the Purple Bus and Word on the Street. These themes were related to new nurses' impressions of the support provided by facility administrators and other nurses, and reputation of the facility.
Theme 1: Get on the Purple Bus
This theme referred to being fully present, embracing the work of the facility in a positive manner, and being part of the team (Gordon, 2007). A past nurse administrator at one of the study facilities had coined the phrase "get on the purple bus" to indicate to employees they needed to be com- mitted wholly to the work of the facility, giving the best possible care to patients, and being supportive of each other. Interviewee 9 said the purple bus was a place where people showed "the love of human life and love of patients."
If you're on the purple bus, it means you want to be here. You want to be here with a smile on your face. You want to be here to take care of your patients. You want to be here to work with your co-workers. You want to be here as a fami- ly.
This main theme included two subthemes: Just Culture and See Me as a Person.
Just culture: This is defined as a, ... process where mistakes or errors do not result in auto- matic punishment, but rather a process to uncover the source of the error. Errors that are not deliberate or malicious result in coaching, counsel- ing, and education around the error, ultimately decreasing likelihood of a repeated error. (American Nurses Association, 2010, para 1)
This subtheme was manifested through new nurses' stories about being treated in a manner they con- sidered "supportive." They indicat- ed they could ask for and would receive help, or they were offered help before even having to ask; they
were allowed to make a mistake, but were not judged harshly for the mistake. Specific examples included comments from interviewee 3: "people ask me and they help me ... I always feel like they help me ... like a sense of teamwork." Interviewee 6 said her peers and nurse manager gave her "the opportunity to learn without feeling as if you're doing something wrong and you're going to be reprimanded for it ... every- one's willing to let you learn." As interviewee 7 expressed, "You're looking for everyone to like, embrace you, and take you in ... knowing someone is there to help you and teamwork ... being patient ... understanding that you are new and ... still learning."
Finally, interviewees 9 and 10 indicated they felt supported by their managers. Interviewee 9 said her supervisor was "someone I can go to when I have a problem ... she was my mentor." Interviewee 10 noted, "My first manager ... pulled me into the office weekly to ask how things were going. She made me feel like I can easily open up to her and come to her with my prob- lems."
See me as a person. In this sub- theme, new nurses voiced how their supervisors saw them as more than a nurse (employee). They felt seen as persons with needs outside the workplace. New nurses said the supervisors and peers recognized their needs for time for school, fam- ily, and personal needs. Interviewee 1 said,
If you have something come up with family, they support you. If you want to go on different ventures, they support you and they let you grow ... when somebody meets you, they know you by name the second time they see you.
Interviewee 2 stated, " ... some- one who works with your schedule ... and understands your life." Interviewee 4 said she felt an "instant connection" when she and the supervisor " ... talked about South Florida ... talked about, you know, life in general and had a nice common ground." Interviewee 2
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also told the researcher she had a medical condition and the willing- ness of supervisors to see her as a person with special physical needs caused her to feel "blessed" to work where she worked.
Theme 2: Word on the Street
The second main theme related to one reason the new nurses decid- ed to take their first nursing posi- tions and to remain in those posi- tions within 1 year of hire. The new nurses researched the facilities' rep- utation in the community. They all mentioned having asked nurses who worked at the facility or other nursing students and faculty who had clinical experiences at the facil- ity about the work culture/environ- ment.
In the original quantitative ques- tionnaire, the primary researcher intended the question to address the hospital's reputation for quality of care as exemplified through measures such as Magnet® designa- tion or Hospital Consumer Assess- ment of Health Care Providers and Systems (HCAHPS) scores. However, the interviewees instead defined the reputation of the facility based on testimonials about how welcoming, nice, and supportive the nurses and other staff at the facility were toward each other.
Interviewees 1 and 7 said they followed their instructors' advice about picking a medical-surgical unit as their first position. Faculty for interviewee 1 reportedly told her to, " ... work on a med-surg unit for the first year." The interviewee also said she got "insider information" and "you start to hear things ... you're gonna like working there, they're great, or they're not" when she went to different facilities as a student nurse. Interviewees 5 and 10 described experiences as student nurses that influenced their first position decisions. According to interviewee 5, " ... they [the nurses on the unit] weren't very nice to me at all" and ... they were actually nicer to me than some of the girls. They [the nurses on the unit] acted like we were in the way" and "the nurses were bothered."
Interviewee 10 said, "One of the
first things I looked at was reputa- tion." She compared two experi- ences at two different facilities where she had completed clinical experiences, saying about one facil- ity, " ... they were catty toward us. Their attitude toward us was nega- tive." Concerning the facility she chose for her first position, she received feedback from " ... several people who work there and they were ... upbeat and very positive about the place." Interviewee 4 also said a nurse she knew had worked as a nursing assistant at the hospital she choose for her first job: " ... he said positive things about the hos- pital as a whole, about the people, the nurses as a whole."
Interviewee 3 said a hospital's Magnet designation " ... didn't cross my mind," but she noted, "[I've] ... always heard good things about [the facility she choose for her first job]." Interviewee 9 commented, "Well, people hear things ... we hear horror stories [about a named hospital] ... horror stories ... I would never even apply! They call it hell." Many participants also men- tioned nurse-patient staffing ratios as a criterion they related to the hospital's reputation. The new nurs- es would hear from nurses who worked at a given facility or see the staffing ratios when they were stu- dents in the facility.
Both overarching themes related to the attitude, work culture and environment, and treatment of new nurses by their supervisors and peers. However, a broader picture emerged of courtesy, respect, civili- ty, and a just culture supported by the facility administrators and all employees as integral factors to their decision regarding the first nursing position. New nurses want- ed to be supported by work col- leagues in a just culture that allowed them to learn and grow in a non-punitive, helping environ- ment.
A factor that did not emerge as a theme but often is considered a recruitment tool was financial incentives (e.g., salary, hiring bonuses, tuition reimbursement, medical benefits). Participants indi- cated salary and benefits needed to
be competitive with other facilities, but none of them identified this as the primary factor when choosing their first positions. They assumed salary and benefits would be similar and fair across facilities. Interviewee 8 said, "I can't say my decision was financially based. Pretty much throughout Louisiana the pay is the same. Tuition reimbursement's pret- ty much the same ... so I can't say that's why [facility name] was my first choice." Interviewee 6 summa- rized, " ... is it really worth a couple extra dollars to not feel comfort- able?" And she said the sign-on bonus " ... locks you into a position for a year ... it's too long of a time if you dislike the place." Interviewee 3 explained her feelings towards a sign-on bonus this way, "I just didn't want to be committed for 2 years, because I'm just not sure where life was going to take me." Interviewee 4 concluded, "I didn't want to be tied down. I didn't want to sign any kind of contract."
Discussion
According to the interviewees in this study, of greatest importance to new graduates is a manager who sees them for what they bring to the organization and how they fit with the team. While equitable pay and benefits were viewed as important, nurses were more concerned with their anticipated workload, flexibil- ity of their schedules, and reputa- tion of the hospital, specifically their unit. Participants overwhelm- ingly chose a hospital based on what others told them or they had experienced personally. What nurs- es say about a hospital or unit, at work and in the community, thus is a stronger recruitment aid than any paid advertisement. Nurses seem to want to know that the facility lead- ers, and more importantly the man- ager, care about them.
Nurses want to feel valued and accepted in the work environment. Despite the stressors faced by the majority of new graduate nurses, graduate transition can be im- proved by supportive institutional practices that foster collegial respect (Chudyk, Klein, Mummery, & Keba,
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Recruitment Attributes Important to New Nurse Graduates Employed on Adult Medical-Surgical Units
Deadline for Submission: October 31, 2020
MSN J1815
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Learning Outcome
After completing this learning activity, the learner will be able to discuss recruitment attributes nurses consider when making decisions for employment on a medical- surgical unit.
Learning Engagement Activity
· Identify the most important factors to new nurse graduates when making first employment decisions.
· What implications does this study have related to manager leadership style?
Fees - AMSN Member: FREE Regular: $20
The author(s), editor, editorial board, con- tent reviewers, and education director reported no actual or potential conflict of interest in relation to this continuing nursing education article.
This educational activity is jointly provided by Anthony J. Jannetti, Inc. and the Academy of Medical-Surgical Nurses (AMSN).
Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Com- mission on Accreditation.
Anthony J. Jannetti, Inc. is a provider approved by the California Board of Registered Nursing, provider number CEP 5387. Licensees in the state of California must retain this certificate for four years after the CNE activity is completed.
This article was reviewed and formatted for contact hour credit by Rosemarie Marmion, MSN, RN-BC, NE-BC, AMSN Education Director.
2016). Hospital leaders may consid- er a transformational leadership model with a strong emphasis on how each unit's manager cares about staff well-being, especially work/life balance.
Nursing Implications
An inherently important factor affecting recruitment for medical- surgical units is the leadership style of the manager. When managers work collaboratively with staff in a transformational leadership style, they are more successful in recruit- ing new nurse graduates. According to Lyons and Kuron (2014), young- er nurses (ages 20-29) are interested specifically in work/life balance and see work as a means to an end, not their sole existence. These authors suggested managing a blended group of older, more experienced nurses and younger new graduates can be a challenge unless the strength of each is leveraged. The younger workforce seeks ever- changing tasks within their work
environment and become easily bored without new challenges; however, work/life balance is their priority. Older, more experienced nurses may create tension between the groups because they are extremely hardworking and may criticize the younger generations for a lack of work ethic and commit- ment to the organization. To be suc- cessful, leaders must leverage the gifts and talents of all staff, identify- ing their motives and empowering them to succeed. Nurse managers also must remember they are always visible. What current and future nurses say about the nurse manager and the unit is critical to future decision making of nurse graduates.
Conclusion
Recruitment of qualified nurse graduates to fill open medical-surgi- cal nursing positions is essential. Nurses want to work in a culture where it is safe to make mistakes and they are treated as individuals (Koloroutis & Abelson, 2017). Nurse
graduates are attracted to institu- tions and nursing units with sup- portive managers and good reputa- tions, where nurses speak favorably of the organization and the unit and nurses are genuinely happy. Impressions portrayed to nurse graduates by current employees may be the greatest recruitment impact factor. MSN
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continued on page 328
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