High turnover in nursing staff is like a plague on home health agencies. Nurses are a very independent breed. Their credentials and qualifications makes them a valuable commodity in the marketplace. Successfully managing and preventing nursing staff attrition is an issue that all successful, highly effective HHA’s must master.
What can HHA’s do to assure themselves that their nurses are happy, fulfilled and productive?
This is the central problem issue for which we seek to find solutions.
First, some introspective questions:

• Do these issues impact your HHA operation?
• What is the average length of employment for your nursing field staff?
• Do you have high turnover?
• Have you really listened to the reasons for dissatisfaction among the nursing field staff?

High turnover costs the agency significant dollars in overall training and lag time between orientation and the staff’s ability to carry a full load. It decreases staff morale and decreases continuity of care for the patients. Some patients get very upset when they have multiple nurses caring for them. They become attached to their original nurse and trust builds. Patient compliance is assured when the relationship with the care provider is strong and trusting.
What can be done to mitigate this alarming and productivity eroding trend?
In their whitepaper, Tullai-McGuinness (2008) state the “attributes reported as important to nurses include autonomy, supportive supervisors, educational support, adequate staffing, good nurse/physician collaboration, and an environment that demonstrates high concern for the patient”. Areas of dissatisfaction identified by Tullai-McGuinness (2008) include “lack of clerical support, ineffective communication with administrators, inability to effect changes in the Home Health Agency and low levels of participation in practice setting decisions”.
By identifying what is important to your nursing field staff and implementing meaningful and direct changes, the potential for the retention of your nursing staff is much higher, and goes a long way in reducing the high costs of retraining. By simply listening to your nursing staff and allowing them to have input into your operational decisions, HHA owners and administrators can directly improve the overall morale of the agency, have better patient satisfaction and thereby manage your agency towards the achievement of better patient outcomes.

5 Ideas to Improve Nursing Retention in Home Health Agencies:

Train and implement a supportive and open office staff to make the job of the field nurse as efficient as possible.
A common complaint from field staff is inadequate information prior to a Start of Care. The field staff is either with a patient, driving or trying to call physicians and do not have the time or the resources to verify information prior to making the appointment. Have your field staff verify that the patient has been discharged from the hospital or rehab prior to sending the nurse out for the Start of Care, verify the address and phone number and verify orders. Make sure that “all of the t’s are crossed and i’s are dotted” so the field staff has all of the information needed prior to that visit. Without this, the nurse is frustrated, looks incompetent to the patient and the agency looks disorganized.

Really listen to input from the field staff. They are the ones on the front line and can give some very good, realistic feedback.
How many times as a field nurse was I informed that I needed to go see a patient 30 miles away but already had 6 patients to see that day? Field nurses know the logistics of field work better than office staff. They are the ones on the road every day. There are variances such as traffic patterns, auto accidents, patients that keep you at their homes for extended periods of time, acuity of the patients, etc. that affect how many patients can safely be seen in a day.
Another example of listening to your field staff would be if your field staff is telling you that a patient does not need further home health care but simply wants to keep their home health aide, do not insist that the nurse recertify that patient. The nurse knows best if the patient really does need further care or is manipulating the situation.

Allow autonomy in making their own schedules. They know how to schedule effectively depending on their assignments on any particular day.
As long as the work gets done, it really doesn’t matter how it’s done. In other words, as long as the staff is following the required regulatory frequency, following physician orders and taking great care of the patient, does it really matter what day they see the patient? While I was in the field, I scheduled my work not only according to frequency (ie. 3xW: Mon, Wed, Fri), but geographically. Why run all over the place if you have groups of patients living fairly close? I would also schedule, if possible, two heavy days, two light days and one day to catch up on paperwork. Just because they do not have a full schedule on a particular day does not mean they do not have a full load. As you already are fully aware–if you don’t properly document, you risk regulatory non compliance and withholding of full payments for the End of Episode.

Ensure that you have adequate staffing to prevent burnout.
There is a fine balance between enough staff to cover the patients and too much staff on the payroll. One quick way to burn out your field staff is to not have adequate staffing. You must account for documentation time and not have the field staff seeing patients from 8:00-5:00 Monday-Friday. They will be doing their paperwork after hours and will eventually burn out and quit. There are many, many home health agencies out there always ready to snatch your field staff. If your field staff gets a better offer with more reasonable expectations, they will leave. Constantly evaluate your census vs staff and ensure that you have enough staff to cover what you have and allow for growth of the agency.

Compensate for a job well done.
“The beatings will continue until morale improves” does not work for too many people. Negative reinforcement is sure fire way to encourage your field nursing staff to seek employment elsewhere. A pat on the back, verbal acknowledgement or a bonus of some kind inspires people to keep up the good work. If a staff member does a good job, let them know. Give them a bonus of some kind. It can be something as small as a Starbuck’s gift card or as large as a bonus check. If finances allow, allocate a reasonable increase in regular pay. Others will hear of the positive rewards for productive work and follow suit. You will get a better response by compensating a job well done than expecting someone to go over and above for no reward.

In summary, an owner who listens to his or her field nursing staff & implements their decisions, positively reinforces productivity in the staff through incentives like pay increases or non cash rewards, and in so doing, proves that their credentialed nursing staff is highly valued, will assure their place as a successful, highly effective HHA.
Nursing staff employment satisfaction increases productivity, increases morale, and improves overall patient care. Listen to your nurses. Let them be responsbile for the operational decisions that effect their productivity. Owners and administrators, by doing this you are doing yourself a favor! Quality care by your nursing staff is what drives excellent patient outcomes, and effective, productive and profitable operations!

Citing: Tullai-McGuinness, S. (2008). Home healthcare practice environment: predictors of RN satisfaction. Research In Nursing & Health, 31(3), 252-260.