The hidden cost of not supporting nurses

Recruitment and retention of nurses in the primary health care workforce will play an increasingly important role in ensuring our healthcare system can meet the complexities of ever-increasing demands.

Coinciding with this growing demand, there is expected to be an acute shortage within the nursing workforce, with a projected a shortfall of 27,000 in the ‘other nursing sector’ workforce which includes primary health care nurses by 2025.¹

The definition of transition may vary according to the disciplinary focus in which it occurs, but generally transition programs involve people’s responses during a passage of change, occurring over time and often entailing some degree of adaptation.² The majority of transition programs for nurses currently exist in acute care settings, however there is considerable scope to expand into the primary health care sector. 

Often nurses have difficulty finding employment in primary health care when they are either transitioning from the acute sector or have recently graduated. It is evident that nursing graduates cannot be absorbed into the acute sector alone.

“Quality patient care and a reduction in costs through careful management of resources are the expectations consumers, insurers, regulatory authorities and government agencies have for professional nurses. Nurse executives are continually challenged to demonstrate the value of registered nurses in providing quality care with limited resources.”³ 

There are some possible solutions, and one of these lies with the primary health care sector. This sector has workforce capacity but urgent steps are needed to increase recruitment and retention within this area of healthcare. Transition to practice programs are one strategy for promoting recruitment and retention.⁴

Supporting transition into primary health care 

Transition programs have the potential to influence recruitment and retention whilst making a positive contribution to the primary health care nursing workforce through the increased knowledge, skills and confidence of those who are commencing work in this area of health. Transition to practice programs are seen as valuable in supporting both the graduate nurse’s professional adjustment into nursing as well as facilitating the experienced nurse’s movement from one clinical setting or speciality to another.⁵

Experienced nurses employed in primary health care acknowledge theirs as an enriching, dynamic and fulfilling career. They also recognise the importance of a structured approach to transition which may address the issues of reduced support and isolation which many nurses experience. It is likely that a supported transition, which includes the guidance of proficient and skilled nurses, can build future leadership capacity and enable increased productivity and innovation in the nursing
workforce. 

There is a perception that nursing experience in hospitals is essential early in a nursing career. As part of a comprehensive consultation contributing to APNA’s work on a career and education framework for nurses, the majority of stakeholders agreed that this is not true, provided there is appropriate support in place for the graduate nurse commencing work in primary health care.⁷ Stakeholders anticipated that the development of a career and education framework for nurses working in primary health care would:

• Work to dismantle the perception that ‘hospital experience’ is required before entering primary health care. Provided the appropriate transitional support is available, no prior experience is needed for a role in primary health care. If we are to encourage nurses to enter primary health care, they need to have the option to enter at the beginning of their career. [KSI 26]. 
• For nurses with experience in hospital environments and who are keen to transition to primary health care, there was acknowledgement that support structures are also required and that, although many skills are transferrable, the context-specific information is different and requires learning.
• The framework will support nurses new to primary health care settings to understand the expectations and professional development opportunities available so they can transition with competence and confidence into a new role.

Without adequate support and direction to assist the transition of a nurse into primary health care, there is a significant risk that nurses will not be retained in the sector and that the cost of nursing staff turnover will be borne by the workplace and our health system. 

Lack of support is costly

It seems that in healthcare, and within businesses on the whole, there is a fundamental lack of understanding about what staff turnover really costs the organisation. In healthcare there is a lack of evidence on the cost effectiveness of care and the quality of patient outcomes (as compared to other industries). It is estimated that when you consider all of the costs associated with staff turnover (across sectors), the real cost to an organisation is significant.⁸

• For entry-level employees it costs between 30–50% of their annual salary to replace them.
• For mid-level employees it costs upwards of 150% of their annual salary to replace them. 
• For high-level or highly specialised employees you’re looking at 400% of their annual salary. 

There are many other tangible costs associated with replacing a nursing staff member. In 2013 an article on employee retention by Josh Bersin of Bersin by Deloitte outlined factors any business should consider in calculating the real cost of losing an employee.(9) These factors include:

• Cost of hiring a new person (advertising, interviewing, screening, hiring). 
• Cost of onboarding a new person (training, management time). 
• Lost productivity (a new person may take 1–2 years to reach the productivity of an existing person). 
• Lost engagement (other employees who see high turnover disengage and lose productivity). 
• Client service and errors (new employees take longer and are often less adept at solving problems). In healthcare this may result in much higher error rates, illness, and other very expensive costs which are not seen by employers. 
• Training cost (over 2–3 years you likely invest 10–20% of an employee’s salary or more in training that is gone). 
• Cultural impact (whenever someone leaves others take time to ask why)².

It is often forgotten that the reduced capacity of a short-staffed workplace negatively influences staff morale and negatively influences patient care. The longer a nurse stays with an organisation, the more productive they become. A stable nursing workforce will have learnt the systems, the patients, the services, and how to work together within a team. 

They have also obtained further education and confidence in the areas of health which commonly present within their primary health care setting. This is not easy to measure in fiscal terms. A transition to practice program across the primary health care sectors benefits patients, the healthcare system and individual nurses.

What is APNA doing about it?

APNA has piloted such a program, and early results have indicated APNA’s Transition to Practice Pilot Program has had a positive influence on nurses’ intention to remain in the nursing workforce. 

Since April 2016, APNA has been supporting nurses transitioning into a variety of primary health care settings – correctional health, aged care, community, Aboriginal health services and general practice – as well as their workplaces as tranche one of APNA’s Transitions program under the Nursing in Primary Health Care Program funded by the Australian Government Department of Health. Nurses in the pilot, who are either recently graduated or established nurses transitioning from acute care settings, have been offered a range of support over the past 12 months. 

"because now I know what I’m doing. That heightens your job satisfaction by 100% when you come in and actually… ‘I know what I’m going to be doing’… ‘I know what is expected of me’, and I know what I’m able to do if I work hard at it. I know what I can get from… I can see a sense of job satisfaction.” [Nurse 059] 

What does support look like? 

The 2016 APNA Transition to Practice Pilot Program comprises a number of components for supporting nurses. 

• Mentoring and preceptorship – the provision of clinical and professional guidance to the transitioning nurse by experienced primary health care nurses.

• Foundational core education activities – providing key information around the core elements of primary health care as determined through key stakeholder interviews. Optional education activities – these activities provide information around additional important aspects of primary health care and are self-selected by transitioning nurses using an individualised selfassessment tool and discussion with support nurses.
• Assessment framework – an interactive selfassessment tool, allowing transitioning nurses to rate their knowledge, skills and confidence levels in both core and optional areas, which is uploaded four times during the 12 month period. 
• APNA support through nurse consultants on staff. 
• Program evaluation – transitioning nurses, mentors, preceptors and workplaces have been participating in telephone interviews and online surveys, completing education activity evaluation forms and sharing their most significant change stories.

The key evaluation questions are:

• How well designed and implemented is the program?
• To what extent does the program effectively achieve its intended outcomes?
• What contextual factors, barriers and enablers impacted on program delivery and achievement of intended outcomes?
• What works, for whom, and under what circumstances?
• What else was learnt?

What have we learnt?

Nurses within the Transition to Practice Pilot Program have described a number of experiences that contribute to what is often termed ‘transition shock’, including orientation issues; unclear role expectations; feeling isolated, alone or lacking support;
being overwhelmed in a new role; a lack of confidence (arising from a knowledge deficit and a lack of well-developed communication and critical thinking skills); and, feeling overwhelmed in the new role.^10,11 Nurses have reported attributing the following to the program: 

• Increasing their knowledge, skills and confidence.
• Increasing role clarity and a strong sense of a supportive environment. 
• Reducing isolation.

Many nurses suggest that the program has contributed to their intention to remain in primary health care through:

• Increased role clarity and job satisfaction.
• Fuelling a passion for primary health care.
• Normalising uncertainty about career decisions.

APNA Transition to Practice Pilot Program model of support - Tranche 2 2017

What’s next?

The 2017 tranche of APNA’s Transition to Practice Pilot Program commences in April. We have taken in feedback from participants of the first tranche as well as key stakeholders and made modifications. This includes moving to one model of support for all transitioning nurses. In essence, regardless of whether nurses are working in isolation or are currently supported by other nurses within their workplace, they can also be supported by an external clinical and professional mentor under the program. 

At the close of applications for the 2017 tranche, APNA had received 108 eligible applications from transitioning nurses and 64 eligible applications from experienced nurses wishing to fulfil the role of clinical and professional mentor within APNA’s Transitions program.

Successful applicants for Tranche 2 of APNA’s Transition to Practice Pilot Program will be announced in March 2017. Read more about the program at www.apna.asn.au/profession/transitiontopractice

Lisa Collison is Project Manager of APNA’s Transition to Practice Pilot Program. Lisa is an experienced registered nurse who has worked for more than 25 years in primary health care, predominately in the community and general practice settings, and much of this in leadership roles. She is passionate about supporting the professional journey of nurses working in primary health care to provide a robust, competent, confident and educated workforce into the future. 

Source: Primary Times Autumn 2017 (Volume 17, Issue 1)

References
1. Health Workforce Australia (HWA): Australia’s Future Health Workforce – Nurses http://www.health.gov.au/internet/main/publishing.nsf/Content/australias-future-health-workforce-nurses
2. Transition: A literature review. Journal of Advanced Nursing 55(3): 320-9 September 2006 https://www.researchgate.net/publication/6919128_Transition_A_literature_review
3. Vanhook, P., September 30, 2007. Cost-Utility Analysis: A Method of Quantifying the Value of Registered Nurses, OJIN: The Online Journal of Issues in Nursing. Vol. 12 No. 3, Manuscript 5.
4. Howe, S. Nursing in Primary Health Care (NiPHC) Program – Transition to Practice Pilot Project (TPPP): A review of Australian and international models of nursing preceptorship and mentorship. 2015 [unpublished]
5. Nursing Workforce Sustainability, Improving Nurse Retention and Productivity,2014 http://www.health.gov.au/internet/main/publishing.nsf/Content/nursing-workforce-sustainability-improving-nurseretention-and-productivity
6. APNA Workforce survey 2016 https://www.apna.asn.au/profession/apna-workforce-survey
7. Wheeler, E. APNA Career and Education Framework Consultation Report. APNA; 2017. [unpublished] 
8. Boushey, H, Glynn S “There Are Significant Business Costs to Replacing Employees” 2012 https://www.americanprogress.org/wp-content/uploads/2012/11/CostofTurnover.pdf
9. Bersin, J. Bersin by Deloitte, “Employee Retention is Now a Big Issue: Why the Tide Has Turned,” 2013 https://www.linkedin.com/pulse/20130816200159-131079-employee-retention-now-a-big-issue-whythe-tide-has-turned
10. Ashley, C., Brown, A. & Brown, E., 2016. Ensuring an efficient primary health care nursing workforce: exploring the transition experiences of nurses moving to primary health care employment. In 2016 Primary Health Care Research Conference.
Canberra, pp. 1–4. 
11. Duchscher, J.E.B., 2009. Transition shock: The initial stage of role adaptation for newly graduated Registered Nurses. Journal of Advanced Nursing, 65(5), pp.1103–1113.