NUR 631 Module 3 Milestone One Example

Milestone One: Framing the Strategic Issue of Medical-Surgical Nurse Turnover and Agency Dependence at Brookfield Regional Medical Center

[Student Name]

Southern New Hampshire University

NUR 631: Strategic Skills for Nurse Executive Leaders

Milestone One

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone One: Framing the Strategic Issue of Medical-Surgical Nurse Turnover and Agency Dependence at Brookfield Regional Medical Center

The environmental scan showed a hospital losing nurses, especially new ones, and paying heavily to replace them. A strategic plan needs more than a list of problems; it needs a single issue, stated precisely, sized in terms leaders understand and tied to outcomes that matter. This milestone frames that issue for Brookfield Regional Medical Center. It argues that turnover and agency dependence are one problem with a common cause, that the problem is costing the organization more than its budget shows and that the evidence links it to patient harm, which makes it a strategic rather than an operational concern.

Sizing the Problem

Brookfield's five medical-surgical units employ about 410 registered nurses. Last year 90 of them left, a turnover rate of 22%. Among the 70 new graduates hired in the prior year, 22 left before their first anniversary, a first-year turnover of 31%. For comparison, a national analysis of newly licensed nurses estimated first-year turnover at about 17.5%, and the authors stressed that differences in how organizations calculate turnover make comparisons difficult (Kovner et al., 2014). Brookfield's rate is well above that estimate by any reasonable definition.

Each departure is expensive. Brookfield's finance office estimates the cost of replacing a medical-surgical nurse at $58,000, including recruitment, 12 weeks of orientation, preceptor time, lost productivity and agency coverage during the vacancy. That estimate is consistent with published work showing that turnover costs per registered nurse run to tens of thousands of dollars and recommending that organizations update their estimates regularly for inflation (Jones, 2008). At $58,000 per departure, last year's 90 departures cost about $5.2 million, and the 22 first-year departures alone cost about $1.3 million. Agency spending of $9.8 million overlaps with some of these costs but is largely additional, since agency nurses are paid premium rates to fill both vacancies and daily shortfalls.

The numbers also point to causes. Exit interviews from the past two years, completed by 48 of the 90 departing nurses, most often cited workload on nights, a lack of experienced colleagues to ask for help and 12-hour schedules that did not fit child care or school. Only nine mentioned pay as the main reason. Preceptors report that they are assigned new graduates while carrying full patient loads, so orientation competes with patient care. First-year nurses are moved to nights at an average of 14 weeks, often before they feel ready. These causes share a theme: the first year at Brookfield asks too much of new nurses with too little support, and the gaps they leave are filled with agency staff who cannot provide that support either. A strategy that pays more without changing the work would leave these causes untouched.

Why It Matters for Patients

Turnover and agency use are not only financial problems. When vacancies leave units short, patients are cared for by fewer nurses or by nurses unfamiliar with the unit. The Pennsylvania hospital data tied heavier assignments to more deaths after surgery and to more burnout among the nurses carrying them (Aiken et al., 2002), and the academic system Needleman's team studied showed that the more understaffed shifts a patient lived through, the higher that patient's chance of dying (Needleman et al., 2011). At Brookfield, night shifts often run at one nurse to six patients against a budget of one to five. The staffing gap is therefore a patient safety issue, and the cycle it creates, heavier workloads leading to burnout and more departures, is self-reinforcing.

The Strategic Issue Statement

The issue can be stated in one sentence: Brookfield loses nearly one in three new medical-surgical nurses in their first year and one in five nurses overall, replacing them with premium-cost agency staff and short-staffed shifts, at a cost of more than $5 million a year in turnover and $9.8 million in agency spending, with evidence that the resulting staffing levels increase the risk of patient harm. This statement names the population, the scale, the cost and the consequence, and it points toward causes the organization can influence, such as the first-year experience and the organization of nursing work, rather than toward factors it cannot control, such as a competitor's bonuses.

Goals

Two measurable goals follow from the statement. First, reduce first-year medical-surgical turnover from 31% to 18% within two years, bringing it near the national estimate. Second, reduce agency spending on the medical-surgical units by 40%, from $9.8 million to about $5.9 million, within three years, without increasing the number of shifts staffed below budget. A balancing measure, the percentage of night shifts staffed at or better than one nurse to five patients, will ensure that savings do not come from simply working with fewer nurses.

Options to Be Compared

The business case in Milestone Two will compare four options: strengthening the new graduate residency with dedicated preceptors and a year-long curriculum; creating an internal float pool of Brookfield-employed nurses to replace agency staff; offering flexible scheduling, including 8-hour and weekend-only positions; and implementing a virtual nursing model, where a seasoned nurse working off the unit by video takes on admission histories, discharge teaching and coaching of new graduates. Options will be judged on five criteria: expected effect on the goals, cost and time to break even, strength of evidence, feasibility with current resources and acceptability to staff. Options can be combined, and the analysis will consider the most effective combination rather than a single answer. The comparison will be presented to the nursing leadership council and the finance committee together, so that clinical and financial judgments are made with the same information.

Conclusion

Brookfield's staffing problem is one issue with a financial, clinical and human cost: new nurses leave, agency nurses fill the gap at a premium and patients face the staffing levels research links to harm. Framing it this way, with numbers and outcomes, gives leaders a reason to invest and gives the plan measurable targets. The next milestone will build the business case.

References

Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA, 288(16), 1987-1993. https://doi.org/10.1001/jama.288.16.1987

Jones, C. B. (2008). Revisiting nurse turnover costs: Adjusting for inflation. Journal of Nursing Administration, 38(1), 11-18. https://doi.org/10.1097/01.NNA.0000295636.03216.6f

Kovner, C. T., Brewer, C. S., Fatehi, F., & Jun, J. (2014). What does nurse turnover rate mean and what is the rate? Policy, Politics, & Nursing Practice, 15(3-4), 64-71. https://doi.org/10.1177/1527154414547953

Needleman, J., Buerhaus, P., Pankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nurse staffing and inpatient hospital mortality. New England Journal of Medicine, 364(11), 1037-1045. https://doi.org/10.1056/NEJMsa1001025