'Use less, lose less, hire more': Inside the strategy that cut nurse turnover at AdventHealth

Two years ago, AdventHealth's nurse turnover rate was 31%. In November, that figure dipped to 18.9% — progress leaders at the Altamonte Springs, Fla.-based system link to a three-pronged nurse staffing strategy: Use less, lose less, hire more. 

"We have seen incredible improvements in turnover," since going live with the approach two years ago, Trish Celano, MSN, RN, AdventHealth's senior vice president, associate chief clinical officer and chief nursing executive, told Becker's

The approach 

Contrary to what one may assume upon hearing the phrase, "use less" is not about reducing nursing staff. Instead, the goal is to leverage registered nurses effectively and ensure they're working at the top of their license through team models that incorporate more licensed practical nurses and patient care techs. Two years ago, LPNs weren't a part of nursing care models across the system's 53 hospitals. Now, 86 units operate on team models and hundreds of LPNs and patient care techs have since been hired. 

The "lose less" component is centered on improving retention and is based on four factors AdventHealth has identified through research as the major reasons why nurses leave: work intensity, leadership effectiveness, career growth and competitive market pay, Ms. Celano said. The health system made targeted changes and put efforts in place to make continuous improvements in each of those areas. With competitive pay, for example, the health system began analyzing market trends quarterly as opposed to annually. 

"The market pay piece is interesting because it really showed us that we had pockets of places where the market was moving faster than we were, and if you don't keep an eye on that, you have nurses who have an opportunity to go work in another facility with pay differentials that are compelling and would probably pull anyone," Ms. Celano said. 

The health system also launched a nursing clinical ladder across every facility to support nurses with career growth and, on the leadership effectiveness front, has invested in tactical leadership development training for nurse managers and assistant nurse managers. Classes as part of that training home in on practical responsibilities nurse managers oversee, such as leading unit hurdles, staffing principles and effective communication with physicians. 

Buckets within the "lose less" strategically overlap and link directly back to the "use less" component, Ms. Celano said. For instance, nurse managers learn about workload intensity and appropriate staffing as part of the leadership development training. 

"Intensity of work is not just staffing. It's three things: acuity of the patient, intensity of the work and the experience of the nurse," she said. "You can have a patient who is low acuity — they aren't a critical care patient — but they are someone who needs to be bathed, fed and walked; that's high intensity.

"That was one specific element of our classes — that our assistant nurse managers understood how to make appropriate assignments and knew when they actually needed to bring another nurse in." 

The third piece of the nurse staffing strategy is "hire more," which is focused on strengthening relationships with the roughly 100 schools AdventHealth works with to identify where future nurses are and build a pipeline.

"Making sure our CNOs and nursing directors are on property at those schools, connecting with the students and showing them what's available at AdventHealth," such as opportunities for nursing students to work as nurse techs, Ms. Celano said. In that role, students get a few additional responsibilities beyond patient techs and familiarize themselves with the organization and units they're interested in working in upon graduation. 

The results

In addition to the turnover improvements, the health system has exceeded hiring goals for experienced nurses and graduate nurses by more than 1,500 year to date, Ms. Celano said. External agency nurse utilization has also fallen from 2,700 24 months ago to less than 500. 

Advancements in turnover and nurse engagement rates have been "proof in the pudding" that the approach is working, Ms. Celano said.

From 2022 to 2023, nurse engagement scores improved on the survey run by Press Ganey, which every bedside nurse completes, aside from nurse leaders. Specifically, AdventhHealth saw improvements in questions around nurse manager ability and staffing. 

"If you want something to work, keep it simple," she said. If it's easy to remember, then every hospital CEO can say "What are our use less strategies? I know there are four of them and let's see how they're working." 

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