Rethinking Nursing on Med-Surg and Telemetry Units

By Rose O. Sherman, EdD, RN, NEA-BC, FAAN

It happened again this past week. A seasoned nurse manager on a medical-surgical unit pulled me aside after a presentation and asked for help with some innovative ideas to manage turnover. The story is the same everywhere I go. New graduates are placed on medical-surgical or telemetry units out of residency programs. Their goals are to move to specialty units as quickly as they can. The cadre of seasoned baby boomer nurses who were the backbone of these med-surg and telemetry units for many years are retiring in large numbers. They are being replaced with new graduates or nurses with just a few years of experience.

Even the best managers find that their turnover has substantially increased and their staffing mix is no longer balanced with experienced staff. These managers are struggling because strategies that have worked well for them historically to retain nurses are no longer working. They want to support the career goals of their staff yet they are stressed by knowing that patient safety and quality are at stake. They also feel under the microscope because their unit turnover has increased. I have seen nothing written about this phenomena in the literature but I hear about it at almost every facility I visit. The employment landscape for nurses has changed as have the career goals of younger staff. The following are some of the new realities in nursing:

Working in specialty units such as ED, ICU and L&D have popularized in the media as being cool places to work. I rarely talk to a new graduate who is not seeking placement in one of these specialties.
Hospitals often put a “one year until transfer to another unit” policy in place trying to combat unit turnover only to find that millennial nurses will seek opportunities with other employers to achieve their career goals.
Medical-Surgical and Telemetry Units are challenging areas to work in for new graduates because the patient care assignments can be significant and the acuity of patients has increased.
Many new graduates plan to return to graduate school to become NPs or CRNAs and specialty experience is often required or highly desired in these programs.
The national turnover rate is hovering around 13% as an average but new graduate turnover is much higher.
Many health systems are rethinking unit turnover as a leadership performance measure and seek retention with the system as the new goal.

It is unlikely that we will see changes in this picture any time soon. Instead, we need to rethink the way we deliver care on these units to make sure this it is safe and of high quality in the face of what could be continuing churn of staff. Two ideas being used in some medical centers that seem promising include:

Convert Medical-Surgical and Telemetry Units to EDUs or Teaching Units

If the trend of short tenures of new graduates on these units is the new normal then why not make these units the educational units that most new graduates transition through. The units could be staffed with seasoned educators or an attending nurse who work with the new graduates on all shifts. The staffing would need to reflect the change in skill mix. Depending on their long-term goals, new graduates could be given flight plans to guide them through goals that need to be achieved before they move into specialty units.

Redesign Care Delivery on Medical-Surgical Units and Telemetry

Primary care may not be the best delivery system on units with a high turnover of staff. These units may need more of a team nursing approach where the teams are led by very seasoned Clinical Nurse Leaders or Clinical Managers who work with new graduates and patient care technicians. Innovative ideas such as incorporating pharmacy technicians to pass medications may be a needed strategy.

Albert Einstein has been quoted as saying that “we can’t solve problems with the same kind of thinking we used when we created them.” I believe this to be true. We will need to be much more creative and it may involve discarding sacred cows. This problem cannot be placed on the plate on these nurse managers with an expectation that they will solve it. We owe it to them and to their patients to rethink what we are doing.