Survey: COVID-19 pandemic takes toll on staffing

The ramifications of the COVID-19 pandemic run deep in the nursing profession. As one respondent to the 2021 OR Manager Salary/Career Survey noted: “[The pandemic has] caused healthcare workers to rethink the reason they went into this profession. Also, the fact that we could die doing our jobs.”

Part of that rethinking by nurses is whether to stay in their jobs or even the profession, for both professional and personal reasons. “Some nurses who have been away from family for over a year because of social distancing requirements] are deciding they don’t want to do that anymore, so they are moving closer to their grandkids,” says Michelle Sanchez-Bickley, MS, SPHR, SHRMSCP, chief human resource officer of Renown Health in Reno, Nevada.

In an early 2021 survey of more than 22,000 US nurses by the American Nurses Foundation (ANF), 18% of respondents planned to leave their positions in the next 6 months, and 4% planned to leave the profession. With OR leaders already struggling to find qualified perioperative nurses, retention is more important than ever.

“Leadership is key to any retention strategy,” says Ila Minnick, MS, BSN, RN, president of Interim Leadership Associates in Rockford, Illinois. “We have nurses who are totally worn out [as a result of the pandemic], so we need to focus on nurse well-being and helping nurses through burnout.” In addition, some nurses who have had COVID-19 may be suffering from its long-term effects.

In the ANF survey, 21% of nurses were undecided about whether they would leave their positions, and 11% were undecided about whether they would leave nursing. The 2020 National Nursing Workforce study, which spanned February to June, found that more than one-fifth of nurses plan to retire over the next 5 years. That adds to the potential number of nurses who could leave, creating not only a patient safety issue, but a financial one as well. According to the 2021 National Health Care Retention and RN Staffing Report, the average cost of turnover for a hospital-based RN was $44,400 in 2020; that’s likely higher for a perioperative nurse. 

The same report found that the average staff RN turnover rate was 18.7%, up by 2.8% from 2019, and vacancy rates were about 9.9%, compared to 8.9% the previous year.

Whether or not the pandemic prompts more nurses to leave, turnover will remain a concern for OR leaders. A pre-pandemic study of more than 207,000 nurses by Koehler and Olds found that 21% of nurses intended to leave their positions in the next year, in line with previous research. 

The pandemic has hit younger nurses harder than their older counterparts. The ANF survey found that 81% of nurses aged 34 years and younger reported feeling exhausted in the past 14 days, compared to 59% of those 35 years and older.

Part of the stress likely comes from the unique situation faced by new graduates—who are usually from younger generations—as a result of the pandemic. These nurses are coming to the workplace less prepared because of reduced clinical time. Leaders need to realize that although simulation helped mitigate some of that loss, new graduates will still require extra time for orientation, especially given that most will arrive with little OR experience.

“We are expanding the orientation time for new graduates, giving them more time in the classroom and in the OR,” says Michelle Hopson, MSN, RN, NPD-BC, director of clinical professional development at Ascension Saint Agnes Hospital in Baltimore. “We want them to feel supported and not overwhelmed, so that they’re more likely to stay.”

Even before the pandemic, however, generational differences played a role in retention. In the Koehler and Olds study, intention to leave varied by generation, with Millennials more likely to respond that they intended to leave than Generation Xers and Baby Boomers.

Those in the Silent Generation were most likely to intend to leave, probably because of retirement. Millennial and Generation X nurses more commonly cited family obligations as a reason for leaving, but Generation Z nurses ranked pursuing a different nursing specialty higher than these obligations.

“Leaders should be aware that the needs of different generations might vary,” says study coauthor Thomas Koehler, BSN, RN, CNOR, a perioperative nurse at John Muir Health-Walnut Creek Medical Center in Walnut Creek, California. “If OR managers can recognize those generational differences and can work with them to retain nurses, it will keep their unit, their team, and their employees closer together.”

One difference is that younger generations are more mobile than older nurses. “You spend a lot of time orienting people for perioperative nursing, and then they leave in 1 to 2 years,” Minnick says. Nurse residency programs can help lessen turnover, but leaders still must meet the unique needs of younger nurses. For example, younger nurses will not sacrifice work-life balance, so mandatory overtime will simply push nurses away.

Sanchez-Bickley agrees: “For the first time, there are five generations in the workplace, and they want and need different things. We try to offer different benefits at different points in someone’s career life cycle.” For instance, help with student loans may be more important to younger nurses than 401K contributions. Older nurses will appreciate knowing how they can make “catch up” contributions to their 401K plans. Renown Health also offers child care benefits and onsite childcare from infancy up to 5 years, which appeals to younger nurses, and it has reduced the amount of time needed for younger nurses to reach higher levels of pay ranges.

Because younger generations want to advance quickly, Renown Health opened its clinical ladder program to new graduates instead of making them wait a year or two. “We’ve found that new grads who participate are more likely to be retained and continue on the ladder,” Sanchez-Bickley says. “It has been a popular program.”

Koehler says research is lacking on which retention strategies work for each generation, but criteria such as pay, staffing, and workload are important to all generations. In fact, workload and staffing were among the most common reasons for intending to leave cited by all generations.

Job embeddedness (JE), a concept developed in the organizational psychology field, can be a helpful way to frame retention. “Job embeddedness is a model that looks more at why people stay in their positions rather than focusing on why they leave. It [creates] a positive perspective when looking at retention,” says Hopson. She was the principal investigator for a mixed-methods study of JE, which has been linked to retention and higher job satisfaction.

“Job embeddedness can be conceptualized as a three by two matrix,” says O. Erin Reitz, PhD, MBA, NEA-BC, associate professor at the Mennonite College of Nursing at Illinois State University in Normal. “It looks at fit, connections, and sacrifice, not only between a person and their organization, but also between a person and their community”. A study by Reitz and colleagues found that JE is a good predictor for a nurse’s intent to stay, and Hopson’s study found that being older, having ties to the community, and having peer relationships were most indicative of JE.

Leaders can use the six aspects of JE to create a retention plan. “Strategies for job embeddedness have to be based on the unique aspects and characteristics of the organization and the community,” Reitz says. For instance, some nurses may prefer to work for a religious-based organization, whereas others prefer a secular one. And some might prefer a smaller town rather than a big city.

Leaders also should consider the strengths and weaknesses of the organization and community. For example, Reitz lives in an area with three schools of nursing, so the links created by students doing clinical rotations in the organization and the fact that most students live in the community are strengths.

As part of her study, Hopson used focus groups and an online survey to collect information about the degree of JE among nurses. OR leaders could use the questions in staff interviews or as a survey. Leaders also could use the survey to assess individual factors such as the work environment.

Links are particularly key when developing a JE-based retention plan. “The more links people have to both the organization and community, the more embedded they are,” Hopson says. She notes that many participants in her study said they would not want to leave the organization because it would mean leaving people they enjoy working with, which reinforces the importance of teams. “Build in opportunities for staff to connect with each other both at work and outside of work,” she says.

“Pay and benefits are important, but as I talk with staff, that isn’t what they bring up first,” Minnick says. “They want a good team to work with. When you work with a good team, there is a lot of satisfaction.” She adds that having a leader (including a charge nurse) who knows how to coordinate care and show appreciation for everyone will help retain staff, which means leadership development is integral for retention.

A common recruitment strategy to avoid is a relocation bonus, which does not promote retention, Reitz says. A relocation bonus may draw a nurse from an urban to a rural area, for example, but in too many cases, nurses return to the original area once their 1- to 2-year commitment ends.

“What’s more effective is to grow your own, focusing on those already embedded in the community,” Reitz says, adding that an educational incentive for a nurse to obtain a BSN or higher education at a local college builds community connection, making it more likely a nurse will stay in the area.

JE requires what Sanchez-Bickley refers to as a “wrap-around” approach that includes a positive job environment and community connections. For example, Renown Health gives staff time off to volunteer in the community and offers classes on how to buy a home. “It’s important for nurses to feel supported,” she says.

Of course, JE is not a panacea for turnover. A study by Marsai and colleagues of more than 300 nurses found that those with low organizational trust but high JE engaged in more workplace deviance than those with low organizational trust and low job JE.

Hopson notes that JE could unintentionally result in nurses staying when they should not, for instance, in the case of lateral violence. In addition, nurses may feel stuck, rather than embedded, because they do not have enough options for growth. To address this, Marsai and colleagues suggest letting employees know about other job opportunities and providing more generalizable skills training.

“There’s no one recipe or template, no magic bullet for nurse retention,” Reitz says. Strategies must be tailored to each organization. “What might work for one might not work for another, depending on the community and the culture of the workforce.”

Even as vaccination rates rise, COVID-19 continues its grip on the healthcare system and are feeling the consequences, including staffing challenges that have prompted a renewed focus on retention. Scars left by the pandemic will complicate retention efforts.

“The pandemic has made things much worse, not only for the nursing shortage but for nurses working in the profession who never had any plans to leave or retire,” says Donna Doyle, DNP, RN, CNOR, NE-BC, perioperative consultant, DJD Consulting Services in Columbus, Ohio. Nurses have experienced personal protective equipment (PPE) shortages, longer work hours, post-traumatic stress disorder, unsafe work environments, and an inability to provide the care they wanted to deliver. Many were furloughed or lost their jobs and did not return when the pandemic eased.

“There has been a loss of trust in the organization they work for and a loss of trust at the state and federal levels,” Doyle says. “This has contributed to the fact that nurses are at the precipice of deciding whether they want to continue to be nurses.”

How can leaders rebuild trust? What else can they do to retain staff? OR Manager provides strategies in several key areas, including work environment, well-being, recruiting and onboarding, and career development.

“One of the biggest ways to retain nurses and help re-establish trust is to make sure you have a safe work environment,” says Doyle. That includes having sufficient PPE, making sure there are mechanical aids for lifting and moving patients, and eliminating smoke in the OR. “Nurses need to feel that the organization is looking out for them and not just looking out for the profit margin,” she says.

Building relationships through communication fosters a healthy work environment. “You have to have an open dialogue between the organization and the staff,” Doyle says, adding that small group and town hall meetings with a Q&A format promote dialogue.

OR leaders should be honest about what can and cannot be done to address issues and about what the organization is doing. “Be transparent,” says Kate Ulrich, MS, BSN, RN, NEA-BC, assistant vice president of nursing, perioperative services at Duke Health in Durham, North Carolina. “It’s important to keep people informed.”

It is also important to listen. “That’s something the pandemic taught us—to listen to team members even more than we did before,” Ulrich says. “On a daily basis, the teams are the ones who are doing the work. We need to listen to be sure they have what they need to take care of our patients.” The “1 Duke Periop” program, which encourages multidisciplinary teamwork, has helped promote staff input, foster collaboration, and implement change where needed.

“You need to really invest time into building a relationship with your team and getting to know them as individuals,” says Michele Brunges, MSN, RN, CNOR, CHSE, director of perioperative services at UF Health Shands in Gainesville, Florida. “The only way you can meet their needs is to understand where they are coming from and what’s important to them.” The organization recently sent leaders to a course on stay interviews (one-on-one interviews that help leaders identify factors contributing to the employee’s retention), which they plan to do quarterly and as part of monthly meetings during orientation, which lasts 6 months (sidebar, “Stay interviews”).

Nurse leaders also should build a strong relationship with HR staff because they can help with tracking turnover and identifying why people are leaving—and staying. HR leaders can calculate retention rates based on predetermined criteria that should remain consistent so trends can be identified. Ultimately, a good work environment is what is going to retain nurses, says Michelle Sanchez-Bickley, MS, SPHR, SHRM-SCP, chief human resource officer for Renown Health in Reno, Nevada. “You have to have good compensation and benefits, but at the end of the day, provided those are where they need to be, it’s about the team, it’s about their leader, and it’s about them having meaningful work.”

“There absolutely needs to be a focus on well-being,” says Ulrich. “We know that many nurses are feeling burned out.” In an early 2021 survey by the American Nurses Foundation (ANF), the top reason nurses gave for wanting to leave their positions in the next 6 months was that work was negatively affecting their health/well-being (insufficient staffing came in close second). Ulrich encourages OR leaders to check in with staff on a regular basis and remove barriers that can impede a nurse’s work.

In addition to an employee assistant program, Duke Health’s chaplain service provides “Tea for the Soul.” Chaplains share different types of tea as they meet with small groups of team members, providing the opportunity to share feelings. Another program is “Caring for Each Other.” Team members who feel the need to talk to someone after a traumatic event can page a multidisciplinary team that includes organizational leaders, a member of chaplain services, and staff from the employee assistance program. “It helps us hone in on what the team member needs at that moment,” Ulrich says.

Doyle says one way to improve wellbeing is to provide a respite room or even a quiet corner that has soft music, aromatherapy, and a yoga mat. “It’s an area where nurses can go when they’re feeling overwhelmed,” she says. “They can get away for even 10 minutes and recoup.”

When Doyle was senior advisor of surgical services at Grant Medical Center in Columbus, Ohio, the facility used Schwartz Rounds, which allow staff to decompress and talk about difficult cases, patients, and families on an emotional level. “This is not just a taskdriven profession; it can be emotionally exhausting and trying,” she says. Rounds were held on units and kept to 30 minutes to facilitate attendance.

Finally, well-being can be enhanced through positive interactions between staff and leaders, which benefits staff. For example, a 2021 study by Sexton and colleagues found that Positive Leadership WalkRounds improved staff wellbeing, with less emotional exhaustion. During rounds, leaders asked staff to share three things that are going well in the work setting, one thing that could be better, and if there is anyone who should be recognized. The rounds improved the culture of safety because staff were more eager to engage in quality improvement activities.

It is not surprising that recognition was part of the rounds, given that employees often state they would like greater acknowledgment of what they do. Brunges says that at UF Health Shands, a perioperative services team meets monthly to create ways to recognize their peers. In addition, the organization has its own recognition program that includes coffee cards, ice cream, T-shirts, and employee of the month.

“For some people, these types of rewards are very important,” Brunges says. She adds, however, that it is important to individualize rewards. “Flexible scheduling meets a lot of people’s needs, but others may have different things they appreciate.”

Retention begins with recruiting the right staff. OR leaders should not rush the process in an effort to plug a vacancy, but rather focus on how a nurse would fit within the organization and team. “For a candidate to love an organization, they have to love their leader, so the more leaders can be involved in the recruitment process, the better,” says Sanchez-Bickley.

Organizations may want to start recruiting even before nurses graduate. Ulrich says Duke Health partners with Duke University School of Nursing to offer an elective course on perioperative nursing. Duke perioperative educators teach the course, which is full every semester. “Nursing students are our future, so we need to expose them to the OR,” she says.

Tight staffing and education staff stretched too thin can tempt OR leaders into shortcutting onboarding, but Rose Sherman, EdD, RN, NEA-BC, FAAN, warns that would be a mistake. “We know that many employees decide whether they’ll stay with employers during the onboarding experience,” says Sherman, adjunct professor at the Marian K. Shaughnessy Nurse Leadership Academy, Case Western Reserve University in Cleveland, Ohio, and author of The Nuts and Bolts of Nursing Leadership: Your Toolkit for Success and The Nurse Leader Coach: Become the Boss No One Wants to Leave. Using a checklist helps standardize onboarding and ensures that nurses both new to the OR and those with experience have a smooth transition.

Sherman recommends leaders be intentional about welcoming staff and showing them they are valued team members. Preceptors are key to this process, so leaders should choose them carefully and provide adequate training.

At UF Health Shands, new staff receive a welcome bag with a notebook, pen, and candy, and their photo is posted on a welcome board outside the OR. Before the pandemic, the leadership team had a luncheon with new employees each quarter. “We introduced ourselves and shared our experiences, and then staff introduced themselves and shared,” Brunges says, adding that they look forward to restarting the luncheons. Sharing often included fun personal information such as stories about pets and children. Regular check-ins with new nurses help to detect problems early. Sherman recommends meeting with new staff at the end of the first week, at 30 days, at 60 days, and mid-year. “Ask how things are progressing, and assess their satisfaction level,” she says.

Sherman recommends starting professional development during onboarding. “Learn about each new staff member’s personal goals for their career, and begin the individual development plan,” she says. “Help new staff develop at least two to three personal development goals.” The goals should include actions and a timeline. Sherman adds that leaders should also have a list of professional growth opportunities for staff to “grow in place” in the OR.

Sanchez-Bickley agrees that leaders should know about available opportunities as well as who is thinking about retiring, moving, or advancing in the organization.

Ascension Saint Agnes Hospital in Baltimore has a nursing career coach. “She works with [nurses] to see if there are other areas where they can thrive so we are still retaining them at Ascension, but we are helping them grow as professionals,” says Michelle Hopson, MSN, RN, NPD-BC, director of clinical professional development. Nurses learn about the career coach in orientation, and the information is posted online.

Nurses can develop their careers by serving as preceptors and mentors. Doyle recommends a combination of traditional and reverse mentoring, where a less experienced nurse mentors a more experienced colleague in a specific area of expertise. “Different generations bring different skills,” she says.

Career development requires leaders to address performance issues. Not doing so is disruptive to other staff. Ila Minnick, MS, BSN, RN, president of Interim Leadership Associates in Rockford Illinois, suggests following the Studer Group’s recommendation to identify high, middle, and low performers. “You want to build and re-recruit [keep engaged] high performers, develop middle performers, and address low performers,” she says. “It only takes one person to impact your entire department.”

Retention depends on developing effective leaders, which Minnick says too often does not happen. “Everyone is so caught up in outcomes, patient satisfaction, and working within financial parameters that leadership development can be overlooked,” she says.

One of the biggest factors for retention is the work environment, so OR leaders should do all they can to ensure a work place where staff can thrive. A culture where appropriate staffing levels are maintained, relationships and well-being are fostered, and employees feel they can grow in their careers will go a long way toward retaining nurses. “Staff want to feel proud of the care that they’re giving. If they can deliver quality care, they will feel good about the organization and hopefully remain in their roles,” Minnick says.

“You have to focus on everybody,” Doyle adds. “Just because somebody has been there for 20 years doesn’t mean they’re going to be there for 21.”