NICU team embarks on recruitment and retention efforts with tremendous results
McMaster Children’s Hospital’s (MCH) neonatal intensive care unit (NICU) can be an emotional place for families to be. It’s where critically ill newborns with a variety of health concerns go to receive intensive care.
It can also be a taxing place to work, especially when there’s a shortage of staff on the unit and workload is high. When you’re caring for the hospital’s smallest and most fragile patients, having enough staff is critical to ensuring each baby gets the time and attention they need.
Staff recruitment and retention became a major challenge post-pandemic. NICU managers Becky Thomas and Maddie White knew they had to make a change when they stepped into their roles in October 2022. They came up with a plan.
The largest NICU in Canada
In 2023, McMaster Children’s Hospital celebrated 50 years of the Neonatal Intensive Care Unit
The NICU at MCH is the largest in Canada, with 72 beds and a team of 400 individuals who provide care for more than 1,500 babies and their families each year.
“In order to provide care in a developmentally supportive way, we need to support patient ratios allowing for the best care,” says Thomas, which is typically one nurse to one or two babies. “Being staffed to our full complement allows us to be in a position to spend the time and attention on how we care and not just what we accomplish each shift.”
A review of the NICU became part of Hamilton Health Sciences’ (HHS) strategic plan. Key stakeholders were brought together to share insights into the causes of concern in 2021/2022 and ways to lead the team into recovery in 2024.
Working groups covered all sorts of topics and included people in all types of roles – doctors, nurses, respiratory therapists, occupational therapists, social workers, lactation consultants, leaders, family partners, and representatives from across HHS’ administrative functions such as quality, organizational development, communications, data management, and decision support.
Recruitment strategies that worked
Thomas and White had their work cut out for them with 40-50 full time nursing positions that needed to be filled. In addition to experienced nurses, the NICU team, in partnership with HHS’ central recruitment team, would recruit help from student placements, extern placements, and nursing graduate guarantee (NGG) positions.
“Moving the dial on how much time we spent ‘reacting’ was important as we shifted toward proactive touch-points and communication.”
They doubled the amount of fourth year bachelor of nursing placements and increased the amount of clinical extern and NGG positions, plus engaged in “pathway conversations” with people in these roles to understand their career aspirations and their desire to work in the NICU long-term. The team collaborated with partners at Mohawk College, McMaster University and Nipissing University, attended job fairs, and advertised on multiple platforms to find the right candidates.
Interestingly, Thomas began her NICU career as a fourth-year McMaster BScN student and White joined shortly after graduation from McMaster.
Moving the dial on proactive retention efforts
Keeping staff on the unit was another challenge.
One major piece of feedback was about the visibility of leaders, so Thomas and White implemented intentional “leader rounding” to visit different areas and talk directly to staff to understand what their needs were.
They also used continuous quality improvement (CQI) tools like pod safety huddles and status sheets which were built-in, standard times throughout the day for discussion, whether between different specialties such as nurses, respiratory therapists and health care aids, or with staff and their leaders. Focusing on these touch-points provided opportunities to get ahead of potential issues, discuss specific patient needs, plan out the workflow, provide operational updates, and escalate care concerns.
“We’re now planning today for what we are going to need tomorrow.”
“Moving the dial on how much time we spent ‘reacting’ was important as we shifted toward proactive touch-points and communication,” says Thomas. “This way, we could get ahead of escalating needs our team was identifying.”
Daily huddles were also an opportunity for people to get to know each other. “Many people on the team are new to health care and the NICU, and evidence shows teams feel they perform better if they know each other’s names, even if other factors, such as resources, stay the same,” says Thomas.
In addition, a new service resource nurse role was added to support nurses in their first year of NICU practice and provide mentorship and additional support to those who may be navigating a new practice or a scenario they have not experienced before.
“Front-line support was reimagined within our new context: of a high percentage of novice staff,” says Thomas. “The service resource nurse role has been extremely well-received by staff and has been a joy for the expert-level RNs who are in these positions to support their team in this way.”
White adds, “With a large cohort of new graduates, we needed to focus on knowledge translation. By utilizing the service resource nurse role, we are able to retain our seasoned RN team members while providing support to our frontline team.”
Professional development
The managers heard that professional development opportunities were important to their team, so they implemented processes for team development days, performance appraisals and proactive succession planning.
“Staff strongly desire a stimulating and supportive environment within which they can grow and achieve development goals, acquire skills and work to full scope of practice,” says Thomas.
Now, the NICU team can expect opportunities to learn new skills so the team has the right roles to provide the best care. For example, scheduling dedicated peripherally inserted central catheter (PICC) days helped alleviate some of the workload off the charge team. To do so, they first had to increase the number of NICU RNs trained to insert PICC lines. “By increasing our team’s skill set we have also seen positive results in patient outcomes as we have a core team with enhanced training and standard work to follow to ensure best practices are adhered to,” says White.
“Evidence shows teams feel they perform better if they know each other’s names, even if other factors, such as resources, stay the same.”
“We’re now planning today for what we are going to need tomorrow,” says Thomas. White adds, “This also helps our team members find joy in work by aligning their interests with available skill sets and training opportunities.”
Managers also increased one-on-one meetings with staff to get to know them and understand how to better support growth and development. And now every staff member who leaves the NICU has an exit interview to learn more about their experience on the team and reasons for leaving.
In-the-moment feedback pays dividends
Part of the retention plan includes increasing recognition opportunities through performance appraisals, celebrations during huddles, sharing patient experience feedback in person and by email, and in-the-moment feedback by peers and leaders.
“We heard clearly from our team that they preferred in-the-moment feedback from teammates and this is an area of focus for us in 2024 in terms of equipping our team to understand how to effectively give and receive feedback,” says Thomas. “If we can remove some of the difficulty around providing feedback, or encourage our team to recognize one another when they’ve done great work or handled something well, that changes the culture on the unit and how individuals feel when they leave after a shift.”
The results
Those 40 vacant nursing positions? Now they’re down to near zero.
“We continue to welcome new team members over the coming months and celebrate their transition from orientation to independent practice,” says White.
In addition to being very close to operating with a fully staffed team, the team saw a shift in why people were leaving their roles when there was natural turnover, through the exit interview process. “With a team as large as ours, we expect turnover – but for reasons that aren’t linked to concerns with their experience while here,” says Thomas.
“When we started conducting exit interviews in October 2022, reasons for leaving were directly linked to challenges staff experienced here in the NICU. Since half way through 2023, there has been a shift. If staff leave, it’s to pursue healthy changes in their lives: relocation to be closer to family in another province or country, pursuing higher education, or pursuing new career opportunities to achieve a different work-life balance.”
“With a team as large as ours, we expect turnover – but for reasons that aren’t linked to concerns with their experience while here.”
The stakes are high
“The goal of the NICU is to leave no evidence we cared for a child,” says Thomas.
This means a child will grow older and no one would ever know they needed the extra care after they were born.
In order to do that, the team needs to be fully staffed, feel connected and valued by their leaders, have the right equipment and training to do their jobs, and have appropriate physical and emotional break space to rest, recharge and connect with one another. When staff are taken care of, they can better take care of their patients.
