Chapter 05: Director of Nursing and Addressing the Serious Turnover Problem

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Chapter 05: Director of Nursing and Addressing the Serious Turnover Problem

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Ms. Alt begins this chapter by explaining the “Mason-Dixon line” that separated inpatient from outpatient care at MD Anderson at that time. She then recounts how she stepped into the role of Director of Nursing after the selection committee had interviewed several other external candidates, noting her initial ambivalence about the role. She then explains how she addressed her primary concern at that tim the 90% turnover rate among nurses. She explains why turnover was so high. She also notes that she was working on a Masters degree at that time, at Texas Woman’s University (MS in Mental Health conferred in 1977), and elected to do her thesis on the turnover problem.[The recorder is paused] Next, Ms. Alt discusses her findings and how she put them to work at MD Anderson, noting that institutional directors were very favorably inclined to evidence based action. Lack of promotion opportunities were a key issue for nurses, and Ms. Alt explains the three-option system instituted in clinical, management/education, and research. She notes that this was a large and very costly program to build and maintain, but it was well supported by Dr. LeMaistre and Mr. Gilley. She observes that they also understood that they had to address problems in the payroll system. She worked with IT to develop a computerized payroll system for nursing. Ms. Alt then reports that at the end of the first year of her service as Director, they institution had reduced turnover to 17%. She notes that Nursing had hired an employee advocate and a mental health counselor. She created a program, “Build Your Own Package,” based on a model she learned from a fire department, that helped with recruitment and retention.

Identifier

Alt,J_01_20180529_S05

Publication Date

5-29-2018

Publisher

The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution The Researcher; Discovery and Success; Professional Practice; The Professional at Work; Collaborations; Leadership; On Leadership; The History of Health Care, Patient Care; MD Anderson Culture; Working Environment; Building/Transforming the Institution

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

Disciplines

History of Science, Technology, and Medicine | Oncology | Oral History

Transcript

Tacey A. Rosolowski, Ph.D:

So as you’re stepping into—well, we were talking about you stepping into the assistant director for nursing role. So, Renilda Hilkemeyer was being replaced or she had already left the position?J

Joyce Alt, RN, MS:

She hadn’t left. [ ] Anderson has a way to—they don’t know how to fire people, so they hide them in [an office] or they put them in the library.

Tacey A. Rosolowski, Ph.D:

Not the first time I’ve heard that.J

Joyce Alt, RN, MS:

[Redacted]

Tacey A. Rosolowski, Ph.D:

So who was acting director at that time?[Redacted]

Joyce Alt, RN, MS:

Patricia Tedder.

Tacey A. Rosolowski, Ph.D:

How do you spell the last name?J

Joyce Alt, RN, MS:

T-E-D-D-E-R. She was really an educator and came—she was recruited to come with the intention that upper management was changing in nursing, and really, they wanted her to come. So, she said, “Oh, I’ll do it for a year, that’s all I want to do it for, is a year.” So she did, she stayed a year, and everyone was shocked that she would leave the great empire and would only be here a year, because she got along very well with physicians, and not as a helper, as a colleague.

Tacey A. Rosolowski, Ph.D:

As a colleague. Interesting.J

Joyce Alt, RN, MS:

It was hard.

Tacey A. Rosolowski, Ph.D:

So why did she leave, why did she choose to leave?J

Joyce Alt, RN, MS:

[ ] [Miss Hilkemeyer was moved to the Office of the President, and they assured them it was not to remove her from nursing but to put her in a position where she could be a stronger advocate for nursing. Both Ms. Teder and Miss Hilkemeyer would be involved in the selection of any candidate for the position of Director of Nursing. Just a short time after that, a candidate from New York was being interviewed for the position. They were very involved in the candidate selection process. Ms. Teder rendered her position at that time and went back to teaching at Texas Women’s University.]

Tacey A. Rosolowski, Ph.D:

That’s interesting. I’ve since learned, in a variety of fields, there are actually people who circulate around in their exclusive roles, to serve as interim or transitional directors, they do. There’s no chance they will stay on, they just serve as a transitional role, and I think that’s really cool, that a person knows that about themselves.J

Joyce Alt, RN, MS:

Yeah, I know.

Tacey A. Rosolowski, Ph.D:

That that’s a real role, you know?J

Joyce Alt, RN, MS:

I don’t think I could have done that. I wasn’t a person who could drop in and… But I know the physicians just hated that she was leaving.

Tacey A. Rosolowski, Ph.D:

Interesting.J

Joyce Alt, RN, MS:

Dr. Freireich, when they started rumblings that maybe I can be considered, he came down and he said, “Well, I’d vote for you but how long are you going to stay?” He’s that kind of person.

Tacey A. Rosolowski, Ph.D:

Oh yeah, I’ve talked to Dr. Freireich. (laughs)J

Joyce Alt, RN, MS:

Is he still alive?

Tacey A. Rosolowski, Ph.D:

He is indeed. He comes in two days a week.J

Joyce Alt, RN, MS:

My.

Tacey A. Rosolowski, Ph.D:

Still goes to Faculty Senate. I still see him at the fitness center with his weight lifting coach.J

Joyce Alt, RN, MS:

[Wow.]

Tacey A. Rosolowski, Ph.D:

I know, he’s a force. Yeah. Cool. So what did you do as assistant director and how did you like that leadership role?J

Joyce Alt, RN, MS:

I liked it but it didn’t last very long, because Pat was here and Ms. Hilkemeyer was somewhere in the building and so it just—assistant directors became directors and you governed a territory. That sounds terrible, governed, but anyhow, you were becoming as specialized as hopefully, the people that you were in this community with. So that’s how that came about.

Tacey A. Rosolowski, Ph.D:

So then, I mean that’s kind of interesting. So you were Assistant Director for Surgical Services and then Associate Director for Hospital Services. Now was that at the same time or different times?J

Joyce Alt, RN, MS:

No, no, different times.

Tacey A. Rosolowski, Ph.D:

So what were the differences in those roles? What was your impact?J

Joyce Alt, RN, MS:

Well, hospital meant it starts here, inpatient and outpatient, and hitherto. I don’t know what it is now but it’s been a Mason-Dixon line almost, between inpatient and outpatient. It was very hard to integrate that, oh goodness.

Tacey A. Rosolowski, Ph.D:

Why was that do you think?J

Joyce Alt, RN, MS:

Well, from my perspective, the physician at Anderson’s home is a clinic and that’s his people, serving his patients and, ‘leave me alone.’ What we were trying to do is get the service, head/neck service, so that the staff here knew as much about what was happening to the patient as the inpatient unit, as this staff should know what’s going on, outpatient. Secondly, when we got in trouble with staffing, your people are ready to go back and forth. That was very hard to—I really tried. I know I didn’t achieve it.

Tacey A. Rosolowski, Ph.D:

I’ve talked to other people in nursing leadership who talked about that challenge too. I mean there eventually was success in creating those environments but very, very challenging. It sounds like, from your perspective it was the MD and the kind of territoriality with the physician that was creating a lot of that.J

Joyce Alt, RN, MS:

[To some degree, yes. Nurses in the clinics] were recognized, they were celebrated. They didn’t have to work evenings or nights or weekends. There were some real pluses to working in a clinic. It was hard but I’ll tell you, [ ] you [rarely] saw the nurses [want to work on the inpatient unit as a permanent assignment]. [ ] Not that it was an easy job, but it was [ ] pressure, it was a different pressure. I had hoped we [ ] [would alleviate that with floating between units. Nurses appreciated physician recognition and in this close working environment it did occur].

Tacey A. Rosolowski, Ph.D:

That’s frustrating.J

Joyce Alt, RN, MS:

Yeah, because I just felt it had to, I mean some time it’s going to have to, because the resources are… I think it would be a more interesting job, not to just see illness all the time, but to see patients improving [along the continuum].

Tacey A. Rosolowski, Ph.D:

Essential for morale too, and retention, I mean all kinds of stuff.J

Joyce Alt, RN, MS:

[ ] We finally worked with the medical staff and said we need a director [at the] unit level. [ ] Some of it was just token, but at least they were included in some of the unit decisions and it improved. Some physicians loved it and others, too busy, you know? So it just comes and goes some.

Tacey A. Rosolowski, Ph.D:

So tell me about getting the opportunity to be Director of Nursing, how did that happen?J

Joyce Alt, RN, MS:

Well, there were a lot of interviews from well-known directors, but just remember, there’s Sloan [Kettering]. There weren’t a whole lot of people waiting out there to come to Anderson with experience. So several came and I guess I wasn’t real impressed, because I felt they were a little bit haughty. It was an attitude. I have trouble with people who think they know it all and own it all, and so I was disappointed.

Tacey A. Rosolowski, Ph.D:

Where did these folks come from, what would have been their home institutions?J

Joyce Alt, RN, MS:

It would have been…

Tacey A. Rosolowski, Ph.D:

Memorial Sloan Kettering.J

Joyce Alt, RN, MS:

Yeah. I know a couple might have been from there, maybe even Dana Farber. I can’t recall.

Tacey A. Rosolowski, Ph.D:

Well there’s a whole Northeast versus Texas thing too, you know, the cultural thing.J

Joyce Alt, RN, MS:

Yeah. And who is number one, Anderson or…

Tacey A. Rosolowski, Ph.D:

Right. Anderson is really the new kid on the block at that time and trying to make a name.J

Joyce Alt, RN, MS:

I don’t think they impressed people as much as they had hoped and maybe that’s just my perception. Some of the staff came to me one day and they said, “Why haven’t you applied,” and I said, “I don’t think I would be one for that role.” [Redacted] Well, somebody nominated me anyway and then, my friend, Dr. Hickey, and I know he has died, he always called me “Iowa Thunder,” So he came down one day, “Iowa Thunder, we have got to do something about this position.” He was from Iowa City, that’s how he got the name of Iowa Thunder, and he said, “Why don’t you consider it?” I said, let me think about it, and he said, “Two weeks, no more.” I said okay and so I talked to others and thought at least I know the system, I have a desire to do a good job, and would want to do a good job, and have a great deal of respect for the staff. (gets chocked up) So, there I was.[Redacted][Change would have to come and I needed support from administration to make it happen. Our] turnover was 90 percent [at that time].

Tacey A. Rosolowski, Ph.D:

Really?J

Joyce Alt, RN, MS:

I took the job.

Tacey A. Rosolowski, Ph.D:

Oh my God. How did that come about, I mean why did that happen?J

Joyce Alt, RN, MS:

Well, several things. Competition in the medical center was absolutely fierce, turnover was everybody’s thorn. No one would share, really, what it was and it became a war of, I’ll pay you. I mean, nurses left for $50 more a week and it was terrible. I was working on my master’s at that time and I just thought, I got a good idea for my thesis. I’m going to study the reason for turnover in an oncology setting, because it was easy to say your turnover is… Poor things, can’t take care of these patients with cancer, all this death and dying. I’d never believed that but I wasn’t real sure either, so I did an open-ended thesis: “You tell me. I’m not going to give you something to rank. You identify what creates turnover in Anderson.” They did and it doesn’t matter whether we liked it or not, it wasn’t that, unlike what was happening at other hospitals; salary, hours, not enough input. Anyway, the most satisfying thing was taking care of the patient with cancer. [I was praying I could make a difference.]

Tacey A. Rosolowski, Ph.D:

Interesting. Yeah, not the biggest burden. So just for the record, you were doing your master’s at Texas Women’s. In mental health nursing, and wasn’t it also [Medical-Surgical]?J

Joyce Alt, RN, MS:

Yeah, I had a bi-master’s.

Tacey A. Rosolowski, Ph.D:

Right, that’s what I thought, and that was conferred in 1977.J

Joyce Alt, RN, MS:

Yes.

Tacey A. Rosolowski, Ph.D:

So just a quick digression, or not quick. Why did you choose to go back for your master’s? J

Joyce Alt, RN, MS:

I knew if I wanted—I had one of the nurses, in fact it was Pat, who told me, she said, “If you want to get anywhere more at Anderson, you must get a master’s.” I thought, ‘oh shoot,’ because I don’t—I mean, I had gotten my bachelor’s working and I thought boy, I don’t know if I want to go through that again, but I did.

Tacey A. Rosolowski, Ph.D:

Was it worth it?J

Joyce Alt, RN, MS:

Oh my, yes.

Tacey A. Rosolowski, Ph.D:

Yeah. What were the payoffs of it?J

Joyce Alt, RN, MS:

What I found out in my thesis was a major benefit of my education. I don’t think I’d have found it out any other way, because I’m not real sure that the environment was such that they would say yeah, come in and study nursing. I’m not so sure that would have… So, I could do this thesis, everybody above me knew what I was doing and why, and it was invaluable.

Tacey A. Rosolowski, Ph.D:

How did you put that information to work?J

Joyce Alt, RN, MS:

That’s where I started building.

Tacey A. Rosolowski, Ph.D:

Okay, cool. And so once you became director, you could act on all this?J

Joyce Alt, RN, MS:

Yes.

Tacey A. Rosolowski, Ph.D:

So tell me what your strategy was there.J

Joyce Alt, RN, MS:

First of all, I published, for the world to see… (gets choked up) [Turnover…] ninety percent.

Tacey A. Rosolowski, Ph.D:

Do you want me to pause for a minute?J

Joyce Alt, RN, MS:

Yes.

Tacey A. Rosolowski, Ph.D:

Okay, I’ll just pause for a second. [pause in recording]All right, we’re returning.J

Joyce Alt, RN, MS:

So, I posted it [on the wall in the nursing office] and said, we’ve got to get rid of this. So we started developing programs. The most satisfying thing was care of the patient and the family, [as identified by our staff].

Tacey A. Rosolowski, Ph.D:

How did you address that?J

Joyce Alt, RN, MS:

I really didn’t go to the unit level, because I didn’t want them to think I was betraying them, because a lot of these folks participated. [I shared findings with the Director of Nursing who turn shared findings with the staff. No one was ever identified by unit or name so the general findings were discussed. I wanted to make sure those who participated were not identified.]

Tacey A. Rosolowski, Ph.D:

Oh, right, of course. Yeah. J

Joyce Alt, RN, MS:

[Redacted]

Tacey A. Rosolowski, Ph.D:

Who were you reporting to?J

Joyce Alt, RN, MS:

Dr. Hickey, [ ] administrator [Dan Oedani and even Dr. LeMaistre at times]. [ ] I mean it just bounced around there.

Tacey A. Rosolowski, Ph.D:

And so having this as a research study, your maters study, that really must have helped with the credibility and building your reputation.J

Joyce Alt, RN, MS:

They love studies. Anderson loves studies.

Tacey A. Rosolowski, Ph.D:

That’s right.J

Joyce Alt, RN, MS:

[They were interested in the findings of the study.] The first thing, I got stationery and I put on it, “An experience in life.” It became my motto.

Tacey A. Rosolowski, Ph.D:

An experience in life?J

Joyce Alt, RN, MS:

Yeah.

Tacey A. Rosolowski, Ph.D:

And what did you mean by that?J

Joyce Alt, RN, MS:

The rewards [of caring for the patient at MD Anderson] is truly an experience in life. So I knew that—I started building it, attacking the turnover, and our salaries, I thought were competitive. Anderson will never be number one [with nurses’ salaries], but we shouldn’t have to be. [ ] [All the medical centers were playing salary games] at that time.

Tacey A. Rosolowski, Ph.D:

Oh really?J

Joyce Alt, RN, MS:

Oh yeah. [ ] The change, as we started, is we built a career ladder. [The way in nursing before the career ladder was to be promoted to a level that you generally were not prepared for. I thought, surely there is a better way. Something is wrong with this practice and thus we build a career ladder program to facilitate the movement of a registered nurse along the track of three components: clinical, administrative, and education. The movement was by promotion with an increase in salary and preparation for the level of advancement. The top position of the clinical ladder was clinical nurse specialist; administrative was head nurse; and there were three levels of educational advancement with the highest level bing a master’s degree in nursing education. The upper levels of all components did not go into even more progressive levels such as PhD or Ed, e.g. The purpose was to prepare individuals at each level to develop a higher level of performance with a monetary reward. I had hoped to develop a fourth rung, nursing research, but this did not materialize at that time.]

Tacey A. Rosolowski, Ph.D:

Okay, that’s when that started.J

Joyce Alt, RN, MS:

[ ] That was a very costly and humungous program to initiate and maintain, but I went to Dr. LeMaistre and Mr. Gilley and I said, I don’t know what else we could do. I don’t want to keep hiring these [temporary nurses or “rent-a-nurses.”] [ ]

Tacey A. Rosolowski, Ph.D:

Right.J

Joyce Alt, RN, MS:

I just said we aren’t getting our money’s worth [from a transient staff].

Tacey A. Rosolowski, Ph.D:

Well, and to take care of patients who have very specialized needs. So what did Dr. LeMaistre say when you laid that out for him?J

Joyce Alt, RN, MS:

He listened. He would never make a decision like that without Mr. Gilley. He said we’ll get back with you. I had all the financials and blah-blah, what the cost of our turnover was. I could at least evaluate that, but the cost of not having prepared people taking care of patients with cancer, who knows?

Tacey A. Rosolowski, Ph.D:

Right. J

Joyce Alt, RN, MS:

They came back and said, “Do it.”

Tacey A. Rosolowski, Ph.D:

Wow. J

Joyce Alt, RN, MS:

That’s after we were spending hundreds of thousands of dollars on rental nurses. But in order to do that, I mean in the meantime, I knew we’d have to have a better payroll system. Our payroll system was—checks were late, checks were wrong. So, I interfaced with our computerized people and I said, “I need this built, this is what I need.” Bless their hearts, they developed a computerized payroll system for us. Now that took time.

Tacey A. Rosolowski, Ph.D:

And this was just for nursing.J

Joyce Alt, RN, MS:

Just for nursing. And then, that allowed me to pay nurses in real time, for overtime.

Tacey A. Rosolowski, Ph.D:

Oh, wow. Do you remember who you worked with?J

Joyce Alt, RN, MS:

Oh yes, Sandra Seelig and Alfred Pulido.

Tacey A. Rosolowski, Ph.D:

Those names were right on the tip of your tongue. (laughs)J

Joyce Alt, RN, MS:

Those people, I’ll tell you, just asked [them to] computerize the nursing record for us, so we could record [daily] dressing changes, [as an example], that are just, it’s something you’re doing every day. [ ] that was a tremendous boost for us. [I know I heard at times, “nursing gets everything,” but we needed nurses to carry the specialized care needs of our patients.][01:010:38]

Tacey A. Rosolowski, Ph.D:

Now let me just ask you a quick question about the career ladders that you built. Was there any controversy about this at the time?J

Joyce Alt, RN, MS:

Honestly, I had a couple doctors come in and say, “Can you help us?” Oh, God, that’s just what I need, getting in big time trouble. I truly did, because turnover wasn’t that great in the medical staff either.

Tacey A. Rosolowski, Ph.D:

Really? Oh, wow.J

Joyce Alt, RN, MS:

What’s happening is younger and younger folks were coming in, and that’s not bad. [ ]

Tacey A. Rosolowski, Ph.D:

Well I mean, a lot of people have talked about the very haphazard mentoring that goes on. How do you know how to get yourself promoted, you know what do you do? And so you were really creating a system for this and that did not exist for faculty.J

Joyce Alt, RN, MS:

No. Well, it didn’t exist for nursing either [when seeking promotion].

Tacey A. Rosolowski, Ph.D:

Yeah, you put in place.J

Joyce Alt, RN, MS:

There was discussion at times, when I’d go to different seminars, there’s a need here to, you know. We’ve got to better educate our nurses and promote them to levels that they want. Well, our interpretation of that was the Career Ladder Program. And then, we went to schools of nursing, four hours [of oncology] isn’t cutting it. So, they had faculty come over and review our [components for entry and promotion], and they did expand [the curriculum] and incorporate some of what we were doing, so at least there wasn’t a sharp value [discrepancy] every time a new graduate walked in our building.

Tacey A. Rosolowski, Ph.D:

Did you find it was difficult to attract nursing students to enter oncology nursing?J

Joyce Alt, RN, MS:

Honestly, I didn’t try, but I wanted to, but having them there and afraid, and I was afraid for the patients. I mean we’re giving drugs that, a wrong drug, [ ] you’re dead, [or impaired]. So, we always worked with the schools of nursing, but to say we’re going to throw a party just for the new graduates? No. We had to get them better prepared to take care of our patients.

Tacey A. Rosolowski, Ph.D:

So how quickly did you start seeing some results from these initiatives?J

Joyce Alt, RN, MS:

By the time I got the [entire recruitment/retention] package bill [in place] [ ], we were down to 17 percent turnover, [the lowest in our nursing history].

Tacey A. Rosolowski, Ph.D:

Wow. Wow. And so that was like under a year?J

Joyce Alt, RN, MS:

I would say it was a year. [It may have taken several years, I don’t recall for sure. This entire effort was a humungous project of job development, implementation, and evaluating.]

Tacey A. Rosolowski, Ph.D:

[ ]J

Joyce Alt, RN, MS:

It was. I hired a full-time counselor that would be available to assist staff.

Tacey A. Rosolowski, Ph.D:

And was this a counselor for—what were the kids of issues that counselor dealt with?J

Joyce Alt, RN, MS:

Whatever the employees [needed].

Tacey A. Rosolowski, Ph.D:

Okay.J

Joyce Alt, RN, MS:

If they needed a place to cry, they needed a place to help better understand the care they’re delivering. And she was available around the clock, was scheduled. A lot of that—and I never got into her business, because they had a trust, that that was between them and her. The only thing she has ever said to me was, “There’s probably as much insecurity and need from external factors, family.” But whatever. They needed it.

Tacey A. Rosolowski, Ph.D:

Do you recall her name, the counselor?J

Joyce Alt, RN, MS:

Yeah. She’s since died. Lee Brown.

Tacey A. Rosolowski, Ph.D:

What an amazing job to have, listening in on them.J

Joyce Alt, RN, MS:

Yeah. And then I employed a full-time employee advocate, and I used that woman, she was my right hand. If I wanted to implement any kind of programs, she was there doing it. She developed employee recognitions. I made sure every Christmas, everybody got a Christmas letter. Big deal. It was to them.

Tacey A. Rosolowski, Ph.D:

Yeah. What was your advocate’s name?J

Joyce Alt, RN, MS:

Francine Wilson. She also has died. Birthdays, you know, things like that. [ ] I wanted her to be the first person to meet a new employee. You get shuffled around so much in personnel, and I wanted that to be a fresh face and helping hand, to introduce them to the Division of Nursing. Then we put in what I called “Build Your Own Package.” We were getting nurses from Louisiana because of that little move. Basically, for example, weekends were very hard to staff still. We said, “You put in 32 hours, 16 hours Saturday, 16 hours Sunday, we pay you for 40.” Those folks didn’t have to come back to work until a week, but they were getting full-time benefits and a 40-hour paycheck. We did that with so many different combinations. I went to a fire department, because I know they have to shuffle [working hours], and I said, “How do you manage your schedules?” They showed me, and I thought well, we can do that. [This] really helped us in recruitment and retention.

Tacey A. Rosolowski, Ph.D:

And the institution backed you financially for doing that.J

Joyce Alt, RN, MS:

Always.

Tacey A. Rosolowski, Ph.D:

Wow.J

Joyce Alt, RN, MS:

One day, Dr. LeMaistre said to me, ’You’re just getting tired of working nights.” I said… (laughs). Yeah. Mr. Gilley was tough as nails but I’ll tell you, he listened [when we talked] patient care. [We didn’t] floss him, [just brought] him the facts. You try to fool around, don’t come back, because he was just very tough, but he wanted us to have what we needed.

Chapter 05: Director of Nursing and Addressing the Serious Turnover Problem

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