Paradigm is an overused word, but it is highly descriptive of the controversial subject I am about to embark on. As both a chief nursing officer and chief executive officer for many years, one of the major tactics I employed to achieve a fiscally viable hospital was to control and ultimately eliminate registries for nurses and other staff. Besides the cost factor, evidence indicates that decreased use of outside agency staff correlates highly with improved quality. This correlation works particularly well with patient satisfaction. Creating a more positive work environment for staff may continue to be valid, but it may not be the most realistic approach in the future. Experience, including my own, has supported the opinion that registries should be decreased. Lately, however, I am questioning whether this paradigm can continue to last and be sustainable in today's environment. In the current and future climate, sustaining staffing levels without registries may not be feasible. This is not meant to suggest that the goal of zero registry staff is not worthwhile, but it is critical to be flexible and open to innovative ways to work with outside staff to achieve organizational goals. This shift in my thinking is primarily a result of observations and conversations with many nurses about what they deem important in their professional and social lives. One of many reasons is recognizing that young nurses and new graduates have a different value system than the baby boomers or their predecessors. Their world is much more about having balance and control over their lives. Although work life may be important, it is not the most important thing. Balancing work, play, and family life is important, but the goal may be elusive unless carefully planned for. Money becomes important as a way of meeting these goals and therefore plays a central role in recruitment and retention. Today's generation has learned to prioritize differently to meet these often diverse goals. For many years I have been an advocate of Hertzerg's theory of satisfiers and dissatisfiers. The concept is that if a salary is competitive in the marketplace, it is neither a satisfier nor a dissatisfier; in other words, it neither demotivates or motivates the worker. Obviously, if the salary is below par, it becomes a demotivator. Satisfiers generally include recognition, control, participation, and so forth. Although this theoretical construct still has its merits, it is also obvious today that a salary higher than commonly found in the marketplace is a significant recruitment and retention mechanism, particularly when combined with flexibility. In an era of nursing shortages in my former setting, we found that an analysis of the cost of eliminating registries had to take into account the rich benefits and salaries that had accrued to our workers because of their tenure. Our staff did not have problems with working requested overtime because at one and a half times their salary, it became a distinct motivator. Quality, however, can suffer when staff must regularly work overtime. This dilemma was addressed through recognition that agencies that assigned nurses on at least a 3-month basis could add to quality when permanent assignments were implemented. This strategy proved less costly than our own staff at overtime pay. The agency nurses liked the flexibility of being in different environments and appreciated the money they earned for this flexibility. In addition, after a set period based on a previously negotiated fee, these nurses could and often did get hired based on their needs and desires and the needs of the institution. Registries that can ensure competency, knowledge, and a permanent assignment are probably here to stay. As unpleasant as this new paradigm may seem at the outset, the creative nursing leader will learn to maximize this new workforce along with regular staff. Looking ahead, as leadership and entrepreneurship continue to evolve in the nursing community, the possibility (I would say probability) exists that nursing units and laboratory and other areas may be outsourced in this century, with the risks shared between the hospital and the outsourcing company. Fifty years ago, the concept of outsourcing food and nutrition services, housekeeping, and information technology was unheard of; today it is common. Outsourcing may not always be successful, but it seems to have great merit within various institutions and may well be a forerunner for nursing's new staffing paradigm. This is just an example of what leadership is all about—thinking ahead of the curve! Examine the workforce, both today's staff and the new people we will be hiring, and understand their value systems. There may be other alternatives to outsourcing, but it is worth some examination. Be proactive and open your vision to new possibilities as you lead for the future, always remembering that the patient comes first.
Read full abstract