Nursing News

Lower Nurse Turnover Linked to Higher Quality Care in Rural Hospitals


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By Jennifer Larson, contributor 

May 8, 2013 - Rural hospitals that have lower nursing turnover and better practice environments may fare better when it comes to ensuring that heart failure patients receive optimal care, a new study from the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative suggests. 

An interdisciplinary team of researchers led by Robin Newhouse, PhD, RN, and Laura Morlock, PhD, tested a quality collaborative intervention in 23 rural hospitals in five states. They worked with site coordinators through in-person meetings, monthly group teleconference calls and the use of an evidence-based toolkit. 

They found that the rural hospitals with low nursing turnover were more likely to implement four core measures for the care of heart failure patients: (1) providing adequate discharge instructions; (2) providing smoking cessation counseling; (3) assessing how well the heart pumps; and (4) ensuring the patient receives medication to relax blood vessels.

Robin Newhouse led a study on rural hospitals, nurse turnover and quality care.
Robin Newhouse, PhD, RN, NEA-BC, FAAN, chair and professor of Organizational Systems and Adult Health at the University of Maryland School of Nursing

“What nurses do makes a difference,” said Newhouse, chair and professor of organizational systems and adult health at the University of Maryland School of Nursing. 

During the study, the nurses who participated discussed their challenges and examined their processes, with guidance and feedback from the researchers. 

“It was about using evidence in the best way that they can to improve outcomes,” Newhouse said. 

The results of the study were published in Medical Care.

Recruitment challenges 

One issue raised by the study is how to achieve low nursing turnover. Many other studies have found links between nurse staffing and patient safety. Among other factors associated with better patient outcomes is lower nursing turnover.

But a major challenge for rural institutions lies in the area of recruitment and retention of health care professionals. 

Laura Morlock: rural hospitals have a harder time replacing nurses.
Laura Morlock, PhD, professor and associate chair for Health Management Programs in the Department of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health.

“In a rural environment, when a staff member leaves, it is so much more difficult…to replace that person,” said Morlock, professor and associate chair for health management programs in the department of health policy and management at Johns Hopkins Bloomberg School of Public Health.

“It’s a frustration for all rural hospitals, I believe,” added Brock Slabach, senior vice president for member services for the National Rural Health Association. 

Geographic isolation and lack of educational and cultural resources are often cited as detrimental when it comes to recruiting many would-be employees of a rural institution. Some candidates also are put off by a lack of additional health care resources--access to specialists, the latest technology and other services. The lack of professional opportunities for a spouse also plays a role. 

As a result, there seems to be a chronic shortage of primary care providers in rural areas. According to a 2011 paper from the American Hospital Association, “The Opportunities and Challenges for Rural Hospitals in an Era of Health Reform,” more than three-quarters of the nation’s rural counties have been designated primary care Health Professional Shortage Areas (HPSAs). That means that the counties have a population-to-primary-care ratio of 3,500:1, compared with the 2000:1 ratio that is considered adequate, per the Health Resources and Service Administration (HRSA). 

Rural institutions must recognize these challenges and be deliberate about their ongoing efforts to recruit and retain staff. And many are doing just that. The most successful ones include elements in their strategic plans that specifically address attrition, said Slabach.

“Retaining the nursing workforce is really vital,” said Morlock. “I think you can’t overemphasize that.” 

The results of this study can help nurse leaders, noted Newhouse. They can examine their own environment in light of this study and then create strategies to foster the retention of their nurses. 

More professional development for rural nurses 

During the study, the researchers learned that many nurses in rural facilities longed for more professional opportunities to learn and to grow. 

Often, rural hospitals don’t offer an official career ladder for nurses, noted Newhouse. But that doesn’t mean that they can’t find other ways to offer development opportunities for their nursing staff. They can help provide links to professional networks that can give them the chance to learn more and to network with other professionals. 

“Forming collaborative networks can be really critical, especially for rural facilities, where you worry that physical isolation can lead to professional isolation,” said Morlock. 

Since nurses working in rural environments need effective and efficient quality improvement tools, these types of networks can provide a vital service. The networks can help them stay abreast of the latest research and evidence-based practices that will help them deliver high quality care—such as the care provided for heart failure patients that formed the basis for the Medical Care study. 

But there are challenges. Many of these nurses may not be able to take time off to travel a long distance to meet up with others or to obtain extra education or information, or there may be other costs that are difficult for the nurses and their hospitals. 

“We have to help them figure out ways to learn from each other in less intensive ways,” said Morlock. 

She added that telehealth may hold some promise in this arena, as many rural hospitals are finding advantages to using telemedicine.



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