Increasing Nurse Retention Through Meaningful Recognition

The Clinical Scene Investigator (CSI) Academy program by the American Association of Critical-Care Nurses (AACN) is dedicated to fostering nurse-driven innovation aimed at enhancing patient care, quality metrics, work environments, and nurse retention. This comprehensive 12-month program combines in-person and virtual interactive learning experiences with monthly classes varying from 4 to 8 hours in length.1 The goal of the CSI Academy is to enable direct care nurses to create positive change by educating and empowering them. The program curriculum is delivered by CSI expert faculty with availability for mentoring and consultation. With the help of the AACN CSI Academy, nurses are able to guide their peers in implementing unit-based change that can be readily scaled for optimum impact. The CSI Academy can play a key role in addressing challenges in the post–COVID-19 era; one of these challenges is the elevated national registered nurse (RN) turnover rate, which surpasses that of other health care professionals.1 Empowering front-line nurses through training programs like CSI is one way that nurses themselves can address the nursing shortage crisis.The impact of CSI Academy projects has been remarkable, resulting in reduced infections, shorter hospital stays, fewer ventilator days, decreased delirium, fewer falls, and a decline in adverse events for patients.2 Furthermore, enhancements in unit environments—driven by changes in staffing models, communication practices, and handoffs—have led to increased satisfaction levels among patients, families, and staff. Beyond these improvements in patient outcomes and staff well-being, participating hospitals have reported substantial cost savings, with an impressive median return on investment of 605%.3At the Los Angeles General Medical Center (LAGMC), the journey with the CSI Academy began in July 2022, with the invaluable support of chief nursing officer Dr Nancy Blake and intensive care unit (ICU) clinical nursing director Dr Rebecca Sandoval. Our LAGMC CSI team, comprising 5 dedicated cardiothoracic ICU (CTICU) nurses and an onsite CSI coach, tackled one of the most pressing issues in health care nationwide, high nursing turnover and poor retention. In the LAGMC CTICU, the 12-month RN turnover rate during 2021–2022 was a concerning 41%, while the 6-month RN turnover during 2021–2022 was 27% (Figure 1). This reflected a broader national trend in health care, in which hospital RN turnover had increased in 2021 over the previous year by an average of 8.4% to reach 27.1%; these high turnover rates result in significant financial losses.4 Addressing this crisis required a deep dive into the working environment, particularly in the context of heightened demands on nurses due to the pandemic and leadership transitions.The AACN Healthy Work Environment (HWE) initiative is a comprehensive framework aimed at improving workplace conditions for critical care nurses and, consequently, health care overall.5 This model focuses on enhancing patient care quality by ensuring a supportive workplace for critical care nurses and health care professionals.5 An HWE is recognized as vital for health care providers’ well-being and directly influences patient outcomes and safety through enhancing workplace conditions and elevating the quality of care provided.5 The 6 standards of an HWE encompass skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership (Table 1). This framework became the foundation, guided by the CSI Academy, as our team embarked on a project titled “Increasing Nurse Retention Through Meaningful Recognition,” with a purpose to improve RN turnover.The LAGMC, formerly known as LAC-USC (Los Angeles County–University of Southern California), has the capacity for 600 beds. It is a level 1 trauma, burn, ST-elevation myocardial infarction, and stroke center. It is an LA County disaster resource center as well as a California Children Services–designated pediatric intensive care unit and neonatal intensive care unit. It has 4 emergency departments, adult, pediatric, psychiatric, and jail, with an average of 180 000 annual visits. The LAGMC is also a US Navy training facility and is on its journey to Magnet recognition.The LAGMC CTICU consists of 10 critical care beds. The patient population includes adult patients who are critically ill or require cardiac or thoracic surgery. The average daily census is 6.2, with 420 patients annually. The LAGMC provides medical services to the medically underserved population comprising Hispanic (69%), Black (17%), Asian (9%), and other ethnicities (5%). Seventy percent of the population is uninsured. In the CTICU, the average number of staff RN is 27, with 3 nursing assistants and 2 clerks.Our CSI Academy journey began with forming the CSI team that included 5 RN staff. The members were invited to participate in the CSI Academy to help identify unit-specific nursing issues, which led to a unit change project centered on improving nurse retention. This initiative involved conducting unit meetings with nursing leaders and staff to identify issues and resolutions. This inclusive approach allowed nurses to voice their concerns and dissatisfaction. After an initial baseline preintervention HWE assessment of the nursing staff, we identified meaningful recognition as the lowest-scoring category. To improve our HWE and address high nurse turnover, our CSI team dedicated our resources, efforts, and focus to improving this standard.Positive self-esteem, perceived organizational support, commitment, job embeddedness, and work group cohesion significantly influence job satisfaction. Meaningful recognition plays a pivotal role in job satisfaction, leading to higher motivation, loyalty, engagement, and productivity.6 It also contributes to decreased nurse turnover, reduced absenteeism, increased job satisfaction, improved job retention, and better patient outcomes and satisfaction. Meaningful recognition mitigates burnout, fosters compassion and satisfaction, supports professional development, and reaffirms the purpose and meaning of nursing. When nurses are meaningfully recognized as essential and valuable team members within the health care system, a strong bond is formed, aligning nurses with the organization’s values and mission. The closer this alignment, the more profound the synergy of meaningful recognition between the individual and the organization.6Inspired by the lively atmosphere of our Los Angeles location, our team chose to inject a “Hollywood” flair into our staff recognition efforts, ensuring that they are not only meaningful but also unforgettable. This choice aligned with our mission to address the high RN turnover, workplace incivility, and low staff morale by tapping into a fundamental human need: gratitude. Gratitude is the act of expressing and receiving appreciation for something or someone.7 According to Emmons,8 gratitude has the amazing ability to reenergize, heal, and inspire optimism when people are faced with challenges. In essence, it can create a healthier working environment—a need that has become even more pressing in the post–COVID-19 era. Data have shown that gratitude can reduce stress, enhance professional and personal relationships, boost resilience, and support job retention.9 Several studies have also highlighted the effect of gratitude on civility in the workplace and its positive impact on patient care quality and safety.10Our gratitude strategies were drawn from the Gratitude Practice for Nurses Toolkit, a collaborative initiative by the American Nurses Foundation and the Greater Good Science Center at the University of California, Berkley.11 Building a culture of gratitude, however, involved challenges, including budget constraints, scheduling conflicts, high patient acuity, declining staff morale, and project burnout from the CSI members during project implementation. Concurrent changes with the nursing workflow arising from a new CTICU medical team also presented a new set of challenges in creating a culture of gratitude. Our initial staff kickoff event focused on educating our unit staff about the newly implemented gratitude strategies and the benefits of cultivating a culture of gratitude for both staff and patient outcomes.The first strategy, derived from the Gratitude Practice for Nurses Toolkit, was named the Hollywood Wall of Fame and resembled a gratitude wall.11 The strategy recognized and celebrated positive contributions, work-related achievements, years of service, and meaningful efforts of our nursing staff. Our creative CSI team members adorned hallways, breakrooms, and walls with decorations to invigorate and reenergize the entire unit. This innovative approach captured the attention of traveling and internal floating nurses, inspiring other departmental units to replicate the idea.The second strategy, akin to Gratitude 123 from the Gratitude Practice for Nurses Toolkit,11 took a more personal approach. Named by the CSI team the Hearts of Gratitude, this strategy involved staff members personally thanking and acknowledging each other’s efforts by writing short messages on heart-shaped paper, which were then placed in a gratitude box on a daily basis. These heartfelt notes were read and announced at the end of each shift and displayed on the Hearts of Gratitude wall strategically positioned near the staff exit. This strategy, while effective, required continuous monitoring to prevent staff from posting notes or messages unrelated to gratitude.The last gratitude strategy, inspired by the Heart and Soul of the Month strategy, was named the Wheel of Recognition and had a twist, prizes.11 This strategy proved to be one of the most impactful interventions in reducing nurse turnover and revitalizing the workplace. We hosted special events twice a month, covering all working shifts, in a unit conference room lovingly referred to as the Nurses’ Safe Haven. Recognizing that teamwork, staff morale, and joy were crucial, the CSI team creatively decorated the room and ensured warm breakfasts were prepared for the staff for all shifts. The funding for these breakfasts and prizes primarily came from nursing leadership and a generous $1000 grant from the Edwards Life Sciences Foundation. These events were brief, typically lasting about an hour. Staff members had the opportunity to decompress from their workload, mingle with colleagues, share stories, and laugh in this nurturing environment. To add an element of excitement and fun, the CSI team introduced the spin-of-the-wheel game, where unit leaders spun a wheel that had each staff member’s name, and the random winners received heartfelt and meaningful recognition emphasizing their unique qualities and prizes such as shirts, pens, and gift cards.The outcome objectives for this project included To evaluate the outcomes of our project, our CSI group used the AACN HWEAT 1.0 electronic survey.12 The HWEAT consists of 24 Likert-type questions assessing each of the 6 standards, with 4 questions per standard. The 6 response options range from poor to outstanding, with potential total scores ranging from 1 to 5. Scoring guidelines for the HWEAT survey are as follows: 1–2.99 indicates “Needs improvement,” 3–3.99 represents “Good,” and 4–5 signifies “Excellent.”12We administered the survey twice, initially in July 2022 to collect preintervention data and again in March 2023 (8 months apart) for postintervention data. We limited the survey to 2 rounds to prevent survey burnout among our staff; each participating RN received a $5 coffee gift card as a token of appreciation.A quantitative analysis was completed using descriptive statistics to compare pre- and postimplementation changes. Mean scores for each question of the HWEAT survey were calculated as well as an overall assessment summary score. The mean scores of both surveys’ standards were compared, including the percent change. The CTICU’s turnover rate was calculated monthly, comparing the 6-month turnover rate preintervention with 6 months after implementation. For the purposes of this project’s financial impact, although it is an underestimate, we limited our calculation to estimating direct costs relating to new RN training. The average monthly salary for a new graduate RN at LAGMC was approximately $7600. On average, the training time of a new graduate nurse to a productive ICU nurse lasted approximately 7 months, for a total of $53 200 used for orientation cost estimates.Approximately 84% of our staff (n = 27) out of 32 participated in the preintervention survey and 20 staff completed the postintervention survey. The preintervention assessment summary mean score was 3.07, which increased to 3.54 in the postintervention data, reflecting a 15.3% improvement. Specifically focusing on standard 5, meaningful recognition, where nurses must be recognized and recognize others for their value to the organization’s work, our baseline score was 2.75, the lowest among the standards preintervention. However, our postintervention score increased to 3.57, marking a 29.8% increase from the preintervention survey and meeting our goal score of above 3.0 (see Table 2).Prior to the project, the RN turnover rate was 27%, which is equivalent to 7 RNs resigning in a 6-month period. In the postintervention period, spanning from October 2022 to March 2023, we observed the resignation of 5 CTICU nurses, a decrease in turnover rate to 19%. In the preintervention period, the cost of training an ICU nurse at LAGMC was estimated at $53 200. From October 2021 to March 2022, we lost a total of 7 CTICU nurses, resulting in a projected fiscal impact of $372 400. The anticipated financial impact of 19% turnover was estimated at a reduced amount of $266 000 (Figure 2).The postintervention survey results for various HWE standards were reviewed. Improvements were observed across different standards: skilled communication showed an 18% enhancement, true collaboration indicated a 17% increase, effective decision-making reflected a 4% improvement, appropriate staffing showed a 13% increase, and authentic leadership demonstrated a 9% rise. Importantly, all standards surpassed the “Good” threshold of 3.0 on the HWE Assessment Tool (HWEAT) based on the postintervention survey data analysis (Table 2).In the HWEAT survey, our preintervention cumulative score was 3.07; the postintervention score of 3.54 reflected a 15% increase in the overall score. It is worth highlighting that for the meaningful recognition standard we had an initial baseline score of 2.75. However, we accomplished a postintervention score of 3.57, a nearly 30% improvement over the preintervention survey results.As we focused on improving the fifth standard, meaningful recognition, we witnessed unintended positive outcomes extending beyond our primary goal. The implementation of gratitude strategies and heightened emphasis on recognition positively impacted all 6 HWE standards. Through this journey, we not only deepened our understanding of the different HWE standards but also witnessed the crucial role that gratitude plays in shaping our day-to-day activities and overall work environment. Our chief nursing officer, Dr Blake, played a vital role in championing the cause of an HWE and offered unwavering support to the nursing staff. Moreover, her involvement provided a platform for our nursing staff to voice additional concerns, allowing for a transparent discussion on how nursing leaders are addressing various aspects of an HWE. This exchange enriched our understanding and highlighted the importance of nurturing a culture of gratitude and recognition. The CSI members also had the opportunity to further develop their leadership skills during this transformative process. This CSI journey created opportunities for the members to accept leadership positions in other unit specialties where they can employ authentic leadership in their practice and mentor future CSI members.The importance of HWEs in nursing cannot be overstated. Nursing is a demanding profession that requires not only physical prowess but also emotional resilience. An HWE significantly affects job morale and, by extension, patient care. Our project successfully exceeded its objective of reducing nursing turnover while concurrently enhancing meaningful recognition, resulting in an environment optimized for health and growth. In recognizing and appreciating staff efforts, it appeared that our unit’s morale also improved as reflected in increased participation in team building events, improved teamwork, and improvement on the National Database of Nursing Quality Indicators, although these metrics were not officially measured as part of our project.Healthy work environments yield benefits not only for nurses but also for the organizations they serve and the communities they impact. Research indicates that HWEs are associated with improved patient outcomes, including reduced mortality rates, fewer adverse events, and enhanced safety measures.13 Although our CSI project initially focused on meaningful recognition, the standards of an HWE are interconnected; improving 1 standard positively influences the others, ultimately fostering an environment characterized by improved patient satisfaction and better quality of care, better survival rates, increased safety, fewer hospital-acquired conditions and other adverse events, decreased length of stay, and fewer readmissions.13 Nurses thrive in such environments, reporting lower burnout rates, increased job satisfaction, and a reduced intent to leave their organization.13Although our project achieved high participation and engagement, the project’s limited duration of 6 months and our small sample size may limit generalizability of our findings. More extensive, high-quality studies are necessary to inform comprehensive evidence-based recommendations regarding HWEs for smaller settings such as our 10-bed CTICU.Our CSI team witnessed the positive correlations to an HWE, including improved patient care outcomes, nurse retention, and positive financial impacts. The complexity of caring for a critically ill patient undergoing heart surgery highlights the need for skilled communication, true collaboration, effective decision-making, appropriate staffing, and authentic leadership. Our project demonstrated the interdependence of the HWE standards in providing the best care possible. Our CSI team embodied authentic leadership, creating a safe haven for staff and management to engage in open and transparent discussions without fear of reprisal. These discussions were crucial in problem solving and team building, ultimately resulting in achieving the CSI goals and objectives. Through our CSI project, we not only improved meaningful recognition but also initiated a culture of gratitude within our unit. The short, bimonthly events in our safe haven played a significant role in team building and fostering a sense of togetherness. Our unit’s success story was recognized within the organization, inspiring other ICUs to embark on their journey toward an HWE by conducting their own HWEAT surveys. This collective effort is changing the organization’s environment, one person at a time, promoting a culture of gratitude, appreciation, and growth.