Telehealth and Solving the Problem of Nursing Turnover

Reducing Nursing Turnover by Implementing Innovative E-Health: A New Strategy for Incentivizing Nurses and Improving Organizational Culture

Problem Identification:

Nursing turnover rates are a serious issue for hospitals: they are costly and result in lost time and energy in continuously training new staff (Twibell, 2012). Identifying the main reasons for nursing turnover and addressing them can lead to better nurse retention (Trivellas, Gerogiannis, Svarna, 2013).

The problem of nurse retention has been identified by academic scholars in journals like the Journal of Nursing Administration, which has estimated the cost of replacing a single nurse to be approximately $82,000 (Twibell, 2012). As Twibell (2012) reports, job satisfaction is the main reason new nurses leave and the poor sense of job satisfaction is related to too heavy workloads and the lack of their ability to guarantee patient safety. While Twibell goes on to suggest that these issues can be addressed by implementing pre-screening strategies when hiring new nurses, such as "pre-hire job shadowing" and "behavior-based interviews," (Twibell, 2012) this capstone project highlights the growing interest among nurses in the area of eHealth and telenursing, which uses electronic monitoring to assist caregivers and help patients to feel more comfortable (Barret, Wallis, 2013; Mills et al., 2013; Odeh, 2014).

E-Health and Telemedicine can be effective innovations in the industry that enable nurses to achieve job satisfaction, as eHealth can help nurses to feel that they are providing better care, making patients more comfortable, and prevent nurses from experiencing workplace fatigue.

The action steps that would be taken in order to implement this strategy include budgeting for eHealth innovation implementation; training workers on how to effectively use eHealth; reviewing the implementation roll-out; making modifications or adjustments as needed. This capstone project will focus on developing an educational framework to facilitate the implementation of eHealth by providing directives, tips, and guidelines on how to use telenursing in a safe and effective manner so that administrators can give their full support to implementation.

Rationale for Change/Innovation

Nursing turnover is costly for hospitals, which have to hire, train, and equip new nurses each time turnovers occur (Twibell, 2012). Hospitals lose millions of dollars per year as a result of nursing turnover. This is a costly problem that needs to be addressed and that can be addressed by adopting an innovative change in the way that hospitals empower nurses. By identifying the causes of turnover for nurses (low job satisfaction, overwork, and an inability to provide quality care), the hospital can boost nurse retention and reduce costs associated with turnover (Mbemba, Gagnon, Pare, Cote, 2013).

The most advanced and innovative way to address this problem is to reshape the organizational environment of the nurses by implementing eHealth services such as telemedicine (Kruklitis, Tracy, McCambridge, 2014). Telemedicine has been shown to reduce the stress that nurses experience from overwork, increase job satisfaction, and help boost the nurse's feeling of being able to provide quality care (Potter, Mueller, Mackinney, Ward, 2014). Telemedicine can be an effect means of empowering nurses and reducing turnover.

By changing the workplace organizational environment and making it more appealing to individuals who want to provide nursing in the Digital Age this innovative technique will help to reduce nursing turnover rates. Thus, this strategy for enhancing nurse retention would therefore help to avoid such high costs associated with turnover and simultaneously enjoy the added benefits of boosting workplace organizational culture and morale by making nurses feel that they are more in touch with the potential afforded them by the rise of digital technology (Kissack, Callahan, 2010).

Causes of the Problem

The causes of the problem of high turnover of nurses have been identified by researchers as general job dissatisfaction, work overload, and inability to deliver quality care to patients (Twibell, 2012; Odeh, 2014). Nurses experience fatigue due to staffing gaps, in which there are shortages of nurses available to make rounds and check on patients as well as to administer over the various jobs needed to be conducted at any one time (Fuhrman, Lilly, 2015). Staffing shortages stem from a need to maintain tight schedules for the sake of budgeting and also because of nursing turnover, as nurses are not available for shifts and others must fill the void (Taylor, 2014). This also leads to overwork, as nurses have to pick up the slack left behind by others, as the wards are insufficiently staffed. Job dissatisfaction results as nurses become frustrated with the workplace culture and environment as it is viewed to be unsupportive of the aims and objectives of the nurses' position, which is to provide quality care to patients (Heuvel, Demoerouti, Bakker, Schaufeli, 2013). How can they provide quality care if they are insufficiently staffed, overworked, and unsupported in terms of having a strong workplace morale and organizational system in place? Thus, the root cause of the problem is that the hospital's ability to support the nurse is inadequately structured: too little support is given to nurses to meet their aims and as time goes on, nurses quit, perpetuating the cycle. In order to stop the cycle, an innovative change to the support system has to be implemented -- one that will allow nurses to provide better quality care without feeling overworked.

With new nurses arriving to the industry being familiar with digital interfaces and having come to adulthood in the Digital Age, it is natural that they would consider eHealth as a welcome advancement in the nursing industry and view it as a positive step and acceptable method of meeting the needs of patients and providing quality care for patients. For this reason telehealth is on the rise and is being viewed as the next step forward in providing patients with the care they desire and making nurses feel more like they can deliver the kind of care expected of them (Trossman, 2014; MayoClinic, 2015). While eHealth is being tried in various hospitals around the country there is still room for growth and implementation; in hospitals where it is not implemented, this project will be helpful as a means of supplying the educational material whereby the proper support can be instituted to make telenursing a reality for nurses, so as to improve their overall job satisfaction and thereby reduce turnover rates.

Identification of Stakeholders

Patients, nurses, physicians, family members, and administrators are all stakeholders in the innovative change recommended here to increase nurse retention in the hospital. A unit manager will be in charge of overseeing the eHealth department, and will thus have power in the innovative process; the manager's interest in the implementation will also stem from his/her role as an administrator seeking the best possible course to quality care; and the manager's influence is seen in the leadership potential of the role throughout the process. An educator will be needed to provide the proper guidelines set forward in this project to ensure that the proper steps are taken and the necessary support system provided for the nurses using the telenursing technology, keeping in line with the recommendations of researchers in the field (Lee, Lee, Kim, 2016). A quality improvement office will also be utilized to assess levels of quality care and staff nurses will be on call to facilitate the telenursing department as part of standard protocol. Family members will also be involved in the delivery of telemedicine as they assist loved ones (patients) in the transition process.

Stakeholders' interest, power, and influence.

The hospital administration will have significant power, interest and influence in the adoption of a telenursing strategy. The power that the administration has is that it can deny or approve the implementation process. Thus the administration is in the most powerful position in terms of whether telemedicine becomes a reality in the hospital. The interest that the administration has in approving telemedicine is that it can improve the conditions of the workplace environment, boost nursing retention, and reduce costs, which will save administrators from having to balance budgetary concerns with hospital objectives long-term. The influence that the administration wields in this innovative process is that it can promote or withdraw support from the project; if it promotes it, it can cultivate a positive morale centered on the implementation of telemedicine. While E-Health is still relatively new to the industry, its success and overall strategic aims have not been popularized and can be considered experimental. Convincing the administration that adoption of e-Health within the hospital would help to improve the organizational culture and create better conditions for nurses to help increase job satisfaction and reduce turnover would be a top priority. The data that is available on how and why e-Health can benefit both nurses and patients will need to be presented to the administration in a convincing manner so as to ensure that positive support is gained from this stakeholder.

Nurse practitioners will need to be educated on how to properly implement e-Health and telenursing strategies, the proper support systems to abide by, and the most effective method of providing quality care via telenursing platforms. Training will be a top priority for nurses. Their power in the innovative process of implementing telemedicine will be in their position to utilize it, grow in experience with it, and through it improve the care of patients and their own working experience. Their interest in the telemedicine innovation stems from their interest to do their jobs to the fullest, and this is a change that will promote that. Their influence in the change will come from those who are experienced with telemedicine, have some knowledge of it, or have a positive outlook on it; they will be able to promote it and generate positive attitudes about it to help sway the administration to adopt it when the time comes.

Physicians will also need to be notified as to the role of telenursing in the hospital and how it is being used to facilitate patient care. Their positive support will be instrumental in providing a high level of supportive morale for employees and for giving adequate attention to the change process. Their power in the project comes from the fact that they can recommend practices to the administration and give support to the project. They have to work with nurses and can see that happier nurses are more effective and that a strategy like telemedicine can improve worker morale. Their influence stems from their power to impress upon the administration the importance of telemedicine, and their interest in the project stems from the fact they collaborate with nurses in the field and want to provide a positive experience alongside them for patients.

The community leaders will also want to be informed on the new implementation of telenursing in the hospital as they will be able to communicate this advancement to their followers and be part of the transition process. Their involvement in the lives of families who may take advantage of e-Health will be viewed as a positive sign. Community leaders have power in the sense that they too can influence the administration and show that patients within the community want to embrace eHealth services because of the quality of care that they can provide. They can give or withhold support to the hospital based on the reaction of the administration to their request for eHealth. Thus, their influence is monetary and also based in public relations. Their interest in the project stems from their desire to see the community served in the best manner possible by local area hospitals.

The only negative risks associated with stakeholders are primarily with the administration, which may not be willing to provide the funding for the implementation. The evidence of the inexorable drift of the industry towards e-Health as a result of total immersion within the Digital Age should help to relieve negativity. Among most nurses, polling indicates that positive outlooks are associated with telenursing implementation and thus there is significant reason to view this strategy as one that could improve nurses' job satisfaction overall (Barret, Wallis, 2013).

Purpose of Project

The purpose of the project is to inform the administration of the hospital on why the innovative change in the hospital by implementing e-Health telenursing communications and capabilities should be adopted to enhance the nursing floor and enable nurses to provide better care to patients by using the means afforded them via electronic and digital technology, which is in line with the direction of the Digital Age and the ease of access that telenursing facilitates. This purpose is therefore geared towards educating the administration about the cost-saving strategy associated with eHealth, how it will help reduce nursing turnover, and why it will be beneficial to both the hospital and the community, and in fact to all stakeholders. Thus, the purpose of the project is not to oversee the implementation of eHealth services, which is beyond the scope of this project (due to time constraints), but rather to start the initiative towards implementing such a policy by addressing the hospital administration.

The project will focus on showing how this innovation will result in higher nurse retention, as nurses will feel better about their ability to provide quality care, their level of job satisfaction will increase, and their feeling of being overworked will decrease, as eHealth technology will ensure that they are properly staffed according to eHealth guidelines designed to support successful implementation. The project will limit its implementation focus to showing why eHealth would be positively impactful in the ICU where telemedicine services will be used to prevent alarm fatigue and help cover nursing staff shortages (Fuhrman, Lilly, 2015).

By educating the administration on the benefits of implementing this innovative change, I hope to benefit stakeholders from administrators on down to patients; informing them of the value of this innovation will ensure that the necessary first steps and supports are put in place so that the hospital is at the forefront of developments in the nursing industry, that it employs the latest, cutting edge equipment and procedures in order to ensure optimal care, and that it is a place where nurses want to work because of the opportunity to work with eHealth technology. Patients likewise will benefit because of the direct attention they will receive while being able to feel comfortable in their own homes; and the hospital will benefit by freeing up rooms and space for more in-patient treatment.

Proposed Solution

The proposed solution to the problem of nursing turnover is to implement an innovative practice at the hospital known as eHealth (alternatively e-Medicine, telenursing, telehealth, etc.). This can only be effected through raising awareness on the merits of eHealth services, and the proper channels must be navigated in order for the awareness to have beneficial outcomes. The proposed solution to beginning the process is therefore to educate the administration through a series of presentations that will inform them of the benefits of the project in terms of a) cost, b) reducing nursing turnover, c) boosting employee morale, d) increasing positive relationships with patients and the community, e) being at the forefront of technological implementation, f) increasing the hospital's prestige, and g) boosting nurse retention.

This process will be conducted by garnering support from nurses and community leaders for the project, preparing a slide show for the administration as well as answers to questions that they will have, and also printing educational material that supports the argument made here in the form of an executive summary where sources are cited and information condensed in a logical, summative flow that explains why the hospital should begin to offer eHealth services in the ICU.

The education of the administration will thus focus on why change that is proposed is for the administration to implement eHealth services at the hospital is for the good of the hospital, the patients and the nurses. As the goal of the project is to reduce nursing turnover, this will be the main point that opens the presentation to the administration: the problem of nursing turnover will be identified; identification of the causes will follow in the slide show presentation; how to address the issue will then be discussed, and eHealth services explained; the other benefits of eHealth services will then also be presented, and in conclusion, the presentation will show that eHealth not only will help reduce nursing turnover but also put the hospital in a more positive position going forward vis-a-vis nurses and patients in the community.

In order for this to happen, I plan to influence the change by developing educational material to give to the administration that will explain why eHealth services will help reduce nursing turnover, boost job satisfaction and improver organizational culture. The educational material will use research in the field on eHealth services, interviews with nurses in the field who have used eHealth, and guidelines for how it should be implemented, what it will cost the hospital, how the system will be supported, who will benefit, and how it will save the hospital money by reducing nursing turnover. As Bhattacharya and Ramachandran (2015) have shown, eHealth is among the factors that can help reduce nursing turnover and boost job satisfaction. Thus, there is evidence of correlation between employing eHealth and increasing nurse retention within the health care industry.

Evidence Summary

Bhattacharya and Ramachandran (2015) have examined the effect of eHealth on the nursing industry using a cross-sectional survey method. Their findings indicate that nurses who use eHealth are more likely to be satisfied with their jobs than nurses who do not. Likewise, they find that eHealth can be an effective strategy in reducing nursing turnover rates.

On implementing a telehealth strategy/system, Odeh (2014) has studied the effects of implementation in hospitals and reported that without a proper preparation and support system in place, eHealth services and telehealth procedures can be severely hampered and produce unsatisfactory results. Thus it is necessary to develop a clear and concise program that communicates roles, responsibilities and procedural techniques along with an efficient management plan to ensure that the implementation of eHealth services is successful. Odeh (2014) points out that technical support is invaluable in this endeavor and that a basic and foundational education on how telenursing works is also essential.

Trossman (2014) has shown that eHealth and telemedicine within hospital ICUs have been helpful in improving quality care for patients, with patient approval ratings increasing after implementation of these systems; other benefits include a reduction in patient mortality, decreases in lengths of stays, and increased savings for the hospital. The key to a successful implementation, Trossman (2014) indicates, is the use of qualified, educated and experienced nurses to help manage the telemedicine system and produce efficient and successful outcomes.

According to Hebda and Czar (2012) eHealth can provide better patient care, safety, attention, cost savings, management of care, management of disease, and more suitable approaches to providing care for aged persons in their homes, which pleases both patients and nurses. Their assessment comes by way of assessing the role of digital technology and electronic communications in the health care industry and viewing eHealth systems as a wholly integrative approach to incorporating Digital Age solutions to modern nursing challenges to effect positive outcomes.

Additionally, Matusitz, Breen and Wan (2013) have found that implementing eHealth systems can "lead to both improved performance in healthcare delivery and reduced deficiencies" allowing nurses to complete tasks more satisfactorily, patients to feel care for with more quality, and the overall nurse-patient experience and relationship to be more fully developed. These outcomes invariably impact job satisfaction and thus boost nursing retention.

Implementation Plan

Plan of Action

The plan of action is comprised a series of stages that build upon another's outcomes to effect the final outcome, which is successful implementation of eHealth services in the hospital.

The first stage in the plan of action is to gather data on the effectiveness of eHealth services in the health care industry. This data will consist of both quantitative and qualitative reports gathered from scholarly journals that are peer-reviewed. These articles will focus on describing first-hand narratives and perspectives on how nurses' experience with eHealth has impacted their workplace organization and the issue of nurse turnover, such as those by Odeh (2014) and Mbemba et al. (2014). This research will be conducted during the first stage of the presentation process, which will last for a period of 4 weeks, from July 1st to July 28th. This material will be gathered and organized into a report provided in the form of an executive summary that can be supplied to administrators as well as civic leaders in the community who are also stakeholders in the hospital's services, as they represent individuals who receive care and can also impact legislation that affects the way in which the hospital conducts business and funds operations.

This brings us to stage 2 of the strategic plan, which is to impress upon administration and civic leaders the importance and value of implementing eHealth services in the hospital. The evidence that is gathered will be used to support the argument and a comprehensive strategic guideline for successful implementation will also be developed along with the report in the final week of the first stage that can be used to show administrators exactly how the implementation process should be designed and structured. Stage 2 of the plan will take place over a 2-week period in August and will consist of a series of planned meetings with administrators (an initial meeting with presentation followed by a follow-up meeting to address questions and concerns, with a concluding meeting to provide precise budgetary information, projected cost savings, and feedback from civic leaders in the community, which is expected to be supportive of the innovative change, as it will enable patients to receive more quality care and nurses to feel more satisfied about performing their jobs).

Stage 3 will be another 4-week course beginning on September 1st and ending on September 28th in which nursing staff members and managers are educated and trained in the benefits of utilizing eHealth services, how to effectively provide telenursing care, how to oversee the transition during the implementation process, the expected outcomes, the tools for measuring the development/implementation of the system, and possible incentives for providing support.

Timeline

The proposed timeline for this capstone project is from July to the end of September, and as its goal is simply to provide the educative material on why and how eHealth services systems should be implemented in the hospital, the actual go-live portion of the implementation process is not included in this capstone project.

Thus the timeline consists of 3 stages of development:

The first stage will last the month of July and consist of 4 weeks of research, and preparation of materials for presentation. The four weeks will be broken down into the following segments:

Week 1: Literature Review and meta-analysis of relevant studies.

Week 2: Literature Reviews continued.

Week 3: Information compiled, organized, and prepared.

Week 4: Presentation development for administrators and civic leaders, including charts, graphs, pamphlets, executive summary, projected budget and projected savings.

The expected milestone achievement in the first stage is the finalization of educational material that can be provided managers, nurses, administrators and public officials/leaders on the expediency of utilizing eHealth, advantages for patients and nurses, and benefits to the hospital.

Stage 2 of the project will consist of a 2-week timeframe in which meetings are held with both administrators and civic leaders during the month of August, showing why eHealth would be beneficial to the public and address the issue of nursing turnover at the hospital.

Week 5: Meeting/presentation with hospital administrators; meeting with civic leaders (city council members, patient groups, health organizations).

Week 6: Follow-up meetings in which feedback is provided, questions answered, and closing arguments made, followed by a decision reached by administrators.

The expected milestone achievement for this stage is the convincing of management to adopt eHealth services at the hospital on an initial scale.

Stage 3 of the project will consist of educating the nursing staff and managers within the hospital on the benefits of eHealth and how to employ it. This orientation exercise will be conducted throughout the month of September and will be overseen and directed by me and other experienced nurses on the floor who are educated on eHealth and passionate about assisting in and supporting the project.

Week 7: Initial opening classes, with educational material provided

Week 8: Introduction to equipment.

Week 9: Identification of techniques, strategies and guidelines for how to provide efficient eHealth services and erect adequate support systems.

Week 10: Overview with practice runs and final assessment of perceived attitudes of nurses towards the implementation.

The expected milestone achievement for this stage will be to educate the nursing staff on how to effectively employ eHealth and to gather data on nurse responsiveness to the concept of eHealth services implementation at the hospital, whether attitudes are favorable, and how the projected outlook in terms of boosting organizational culture and expected job satisfaction levels may be defined.

Required Resources and Personnel

The projected requirements for this project consist of the following materials:

Printing resources and materials (materials may be printed at the hospital so there is no budgetary concern here)

Computer for conducting organizational tasks, such as storing information and locating peer-reviewed articles

eHealth equipment (purchased by the administration, costs unknown at this time, but a budget will have to be developed and specific instruments identified for possible purchase in order to create an effective orientation/educational class for the final stage of the project)

classroom space (this can be found at the hospital and utilized for the purpose of conducting the final stage of the project)

The projected requirements in terms of personnel needed to complete this project will depend upon which nurses on the floor are familiar with eHealth and show enthusiasm for the project. Ideally, the experienced RNs will have favorable attitudes towards the project and participate in the classroom stage of the project plan. This would consist of 3 nurses to help me with the set-up, orientation, and induction processes, as well as to answer questions that the nurses in the class might have and to offer encouragement.