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Integrating Holism

Integrating Holism into the Hospital Setting to Reduce Nursing Turnover Gayle Kipnis University of New Mexico 2007

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Abstract Nursing turnover is costly for healthcare organizations and creates instability in the workforce. In today’s competitive healthcare industry, administrators must make informed decisions in managing financial and human resources that create safe, high quality care while continually increasing satisfaction of registered nurses and patients. Nursing turnover rates can be lessened by increasing job satisfaction through creating workplace environments that give emphasis to caring and healing. This paper proposes to integrate holism into the hospital setting at Flagstaff Medical Center through the Whole-Person Caring Transformational Healthcare Leadership educational program as a solution to reducing nursing turnover utilizing Watson’s Caring Theory.

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Integrating Holism into the Hospital Setting to Reduce Nursing Turnover In this new millennium, healthcare organizations (HCOs) have unprecedented challenges and opportunities. The challenges include delivering the best patient care at the lowest cost while increasing patient and nurse satisfaction. HCOs have come to realize that developing new and innovative ways to promote nursing job satisfaction will reduce turnover rates, enhance patient satisfaction, and increase profits. One such innovation is to educate nursing and multidisciplinary staff in a holistic curriculum called the Whole-Person Caring Transformational Healthcare Leadership Program (Thornton, 2005). This three-phase educational process promotes self-care, self-healing, transformational leadership, and true caring. This paper proposes to integrate holism into the hospital setting at Flagstaff Medical Center through the Whole-Person Caring Transformational Healthcare Leadership educational program as a solution to reducing nursing turnover utilizing Watson’s Caring Theory. Meaningful, holistic, whole-person caring is what is missing in today’s healthcare environment. The result of not being able to provide deep caring to one’s patients is reflected in the following statement by Press Ganey Associates (2006): Most people who choose to work in healthcare do so because they have a high sense of dedication to improving the health and well-being of their fellow man. Those who feel that their organization has deserted that goal are often the most dissatisfied with their work. This type of dissatisfaction cannot be fixed with an increase in pay or better benefits; it can only be addressed with proper attention to the primary goal of health care—care. (p. 4) Significance of the Problem Nursing is our nation’s largest healthcare profession with more than 2.9 million registered nurses nationwide. Nurses also represent the largest single component of hospital staff

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(American Association of Colleges of Nursing, 2006a). In March 2005, the Barnard Hodes Group released the results of a national poll of 138 health care recruiters and found that the average registered nurse (RN) turnover rate was 13.9%, and the RN vacancy rate was 16.1% (American Association of Colleges of Nursing, 2006b). The average cost to replace a RN within a HCO can range from $62,100 to $67,100 (Jones, 2005). A turnover rate of 13.9% to a hospital that employs 500 full-time nurses translates into a cost of $4,036,500 to $4,361,500 each year. By decreasing the RN turnover rate by 1%, or five nurses, a hospital that employs 500 full-time RNs would save $310,500 to $335,500. Fueling this further is a nationwide shortage of nurses which creates additional opportunities for RNs to change jobs in search of better working conditions while hospital’s attempt to decrease their turnover rates. Financial Impact The financial impact of high RN turnover is enormous. This can be measured in loss of future returns, a lessened short-term productivity due to instability in the workforce, the costs of hiring temporary nurses, and new RN orientation and training, along with the loss of productivity until they are fully capable of managing a full patient assignment. Added to this is the potential for not being able to staff adequate numbers of RNs, increasing nurse-patient ratios and nurse turnover and diminishing quality of care and patient safety. In Arizona, the impact of workforce shortages is reflected in statewide emergency department overcrowding and diversions, reduced staffed beds, and an increased surgery waiting time or cancellations that far exceed national averages (Arizona’s Workforce Shortage, 2006). Nurse satisfaction and safety must also be considered a financial impact. Dissatisfaction can lessen unit cohesiveness and create additional turnover. Patient satisfaction, perception of care,

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and loyalty also has tremendous financial consequences because a HCOs positive reputation translates into new and return customers in the future. Flagstaff Medical Center Flagstaff Medical Center (FMC) is a 271-bed hospital that operates under the parent healthcare organization, Northern Arizona Healthcare. It is located in Flagstaff, Arizona, with a population of approximately 60,000. FMC is in a unique environment, as it is the only public hospital within a 50-mile radius, with the closest metropolitan hospital being 140 miles away. Geographic location combined with a high cost of living makes recruitment difficult. FMC is a private, nonprofit hospital that employs 682 RNs of which 576 are female and 106 are male. A breakdown of the nursing staff’s educational backgrounds is 46.22% ADN, 46.79% BSN, 3.28% MSN, and 0.143% PhD. The RN annual vacancy rate for fiscal year 20052006 was 10.6%, which is considerably lower than the national average of 16.1%. However, the RN turnover rate during the same time frame was 15.68% which exceeded the national average rate of 13.9%. FMC has conducted a series of surveys designed to evaluate satisfaction levels within their workforce. The FMC 2005 employee engagement survey Q12 (Appendix A), conducted by the Gallup Organization demonstrated lower than average scores in several areas. Participating RNs reported a disconnection from the mission of the organization, inability to do their best every day, and uncertainty about what is expected of them at work. A sampling of the previous employee satisfaction survey conducted in 2003 by Management Science Associates (Appendix B), showed a slightly higher rate of dissatisfaction when compared to industry mean values in the areas of administrative trust, honesty, and caring about employees, manager and departmental communication, benefits, resource utilization,

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physician relations, shared values and opportunities to participate in organizational-wide and departmental decisions (Appendix C). The impact of reduced job satisfaction among FMC nursing staff is also reflected in the continuous patient satisfaction surveys by Professional Research Consultants. Results showed lower scores in two out of three key drivers and in all areas of nursing care for fiscal year 2006 than in fiscal year 2005 (Appendices D and E). These results are puzzling since in March 2004, the FMC Central Council voted the model of holistic nursing as their framework of nursing practice (Appendix F). This was aimed at providing a unified, meaningful vision for staff nurses during preparation to become a magnet designated hospital. Literature Review Measuring Nursing Turnover and Costs Nursing turnover is considered external when a RN terminates employment within an employing HCO or internal when a RN changes jobs or positions with their employing HCO. There are significant costs involved with each type of nursing turnover. Internal turnover usually generates very little effort at understanding or reducing turnover because it is not perceived as an organizational loss and is not tracked by most hospitals. Often times it suggests that there are professional growth opportunities and advancement available within their HCO. However, if it costs more to replace the nurse who changes jobs within the HCO than it does to fill the vacancy that is being filled, losses may result. External turnover has deep financial costs as the nurses leave the organization. The system that a HCO utilizes to track the cost associated per RN turnover will result in differing estimates. Many hospitals have used the traditional Nursing Turnover Cost Calculation Method (NTCCM) which measured varying visible costs, such as advertising, recruiting, and

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hiring, with some organizations looking at less visible costs such as termination and orientation (Jones, 2004). Lacking uniformity, these figures were generally not comparable. Studies using this method have estimated costs during 1990-2004 ranging from approximately $10,100 to $64,000 (Jones, 2004, p.46). This lack of uniformity, comparable data, and conflicting estimates left HCOs without quantifiable estimates of RN turnover. Integrating Human Capital Theory into the traditional NTCCM has assisted administrators to view RN turnover in a more reliable and accurate method. Human Capital Theory refers to the skills, knowledge, and abilities of individuals as human capital which can increase productivity and generates a return on investments (Cohn & Geske, 1990). The human capital returns can be higher wages, increased benefits, and future opportunities. Organizational efforts aimed at creating a rewarding work environment and improved compensation plans in order to gain a stable, high-quality workforce increases revenue and enhances reputation (Jones, 2004). Nursing turnover, according to Human Capital Theory, is viewed as an individual investment with an expected return. Nurses that view their present employer as being able to fulfill their career growth, compensation expectations, job satisfaction, and life fulfillment goals are less likely to leave. Thus, the organization achieves a return on their investment. By developing human resource accounting methods from Human Capital Theory, value is given to RNs and the costs associated with turnover can be calculated by comparing productivity or revenues with the investment that the organization has made in them. The actual equation for nursing turnover is made by dividing the number of RNs who turnover in one year into the average number of RNs employed during that same year and multiplying that number by one hundred. Incorporating Human Capital Theory and human resource accounting methods, the

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updated NTCCM provides a more uniform and comparable method to calculate costs associated with RN turnover. Jones (2005) conducted a retrospective, descriptive design study of fiscal year 2002 of nurse turnover cost data at an acute care hospital with more than 600 beds utilizing the updated NTCCM (Jones, 2005). Data was gathered at the service and hospital levels to improve accuracy. To ensure its validity, the study design only included external turnovers since many hospitals do not include internal turnovers data in their calculations. Three service lines composed of 419 full-time nursing positions were studied including surgery, women’s, and children’s units. The RN turnover rate was found to be 19.4%, compared to 18.5% hospital-wide. Costs were separated into two main categories, prehire and posthire. Prehire included advertising and recruiting, vacancy, and hiring costs. Posthire included orientation and training, newly hired RN productivity, preturnover productivity and termination costs. A comparison of data from the traditional NTCCM and the updated NTCCM criteria revealed the majority of turnover costs were not fully captured in the traditional NTCCM. Most importantly, the vacancy costs of the updated NTCCM were 72%-78% higher than the amounts cited when the traditional NTCCM was utilized. Vacancy costs reflect the costs to an organization while attempting to replace nurses. According to the updated NTCCM, vacancy costs include hiring temporary nurses, overtime of employed RNs, patient deferrals, closed beds, and loss of productivity of permanent staff attempting to cover the RN who has left. Only overtime was included in the vacancy cost category in the original studies using the traditional NTCCM. The updated NTCCM revealed costs totaling $62,100 to $67,100 per RN turnover (Jones, 2005).

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Nurse turnover consumes resources that might have been directed toward more positive endeavors such as nurse retention or staff development. Knowledge of nurse turnover and the related costs can serve as an impetus for taking action to alleviate the extremely negative consequences. The updated NTCCM is a useful tool that could establish a standard for measuring organizational practices and programs aimed at improving the working environment of nurses, improving quality of care, and reducing nursing turnover. Nursing Turnover as it Relates to Nurse and Patient Satisfaction The financial impact of RN turnover should not only be measured in human capital losses. Qualitative data such as job satisfaction, patient satisfaction, loyalty, and perception of quality of care can also have an economic impact. In times of high RN turnover, health care quality may suffer. An increase in nurse-patient ratios imposes undue stressors and compromises safety. Nurses become exhausted and dissatisfied. In addition, a nursing shortage directly affects patient satisfaction. A variety of studies report a strong correlation between nurse-patient ratios and patient satisfaction. A failure in one is directly related to a failure with the other (Press Ganey Associates, 2004). In 2004, Al-Mailam and Fahad surveyed a random sample of 420 inpatients in a 110-bed hospital that showed a positive correlation between patient’s perception of nursing care and their overall satisfaction with the care at the hospital. This same study also reported a significant positive correlation with patient satisfaction and their reported intention of returning and recommending the hospital to others (Al-Mailam & Fahad, 2005). Aiken, Clarke and Sloane (2004) conducted a cross-sectional, multi-site survey of 10,319 nurses employed in 303 adult, acute care hospitals which examined the effects of nurse staffing and organizational support for nursing care on nurses’ dissatisfaction with their jobs, burnout,

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and nurse reports of quality of patient care. The results reflected nurse’s reports of low quality care were three times as likely in hospitals with low staffing and organizational support for nurses as in hospitals with high staffing and support. Dissatisfaction, concerns about quality of care, and burnout were common among hospital nurses (Aiken). Adequate staffing and HCO support for nursing are key to improving quality of patient care, lessening nurse job dissatisfaction, burnout, and to lessening nurse turnover. In April 2005, the American Nurses Association’s (ANA) survey of 76,000 RNs explored levels of job satisfaction utilizing their National Database of Nursing Quality Indicators (NDNQI). High levels of satisfaction were reported with regard to interactions with other RNs and professional development. Moderate levels of satisfaction were reported regarding all other areas of their jobs which included nursing administration, management, physician interactions and their own level of autonomy. The lowest levels of satisfaction were reported regarding decision-making and tasks (American Nurses Association, 2005). These results are disheartening. Of the 206 hospitals these nurses worked in, 43% had achieved magnet recognition, considered to be the premiere hospitals for RN employment. When 1,045 nurses were surveyed by the Barnard Hodes Group, the top four reasons that RNs left their last employer were failure to value their employees (27%), lack of professional respect in the workplace (26%), too much work and not enough staff (24%), and lack of confidence in management (22%) (Keefe, 2006). Nurses who felt valued identified the top four HCO attributes as support for professional development (19.2%), a management structure open to employee feedback (19.1%), flexibility (16%) and a caring atmosphere (14%) (O'Brien & Lillis, 2006).

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Figures derived from an independent survey that assured anonymity (Keefe, 2006) reported significant disillusionment with employers following a honeymoon period of time. Before joining their present employer, 46% of nurses perceived a caring environment, which dropped to 5% after the honeymoon was over. Fifty-seven percent identified their prospective employer as being a source of quality care which subsequently dropped to 27%. Only 22% of the 42% of nurses who viewed their HCO as fair and honest prior to employment continued to feel this way. Williams (2005) conducted a study that explored specific aspects of RN job satisfaction that contribute to organizational trust. Trust has social and economic value in HCOs because trust is an important aspect of creating organizational stability and a demonstration of concern for the well-being of employees. William’s study was conducted in a 302-bed acute care community regional hospital in the northeast. Two surveys were utilized to assess the extent of RN satisfaction and their sense of organizational trust. The surveys were mailed to the homes of all 920 full and part-time RNs, with reminders later sent via postcard and included in the hospital newsletter. After four weeks, 472 surveys were returned representing 51.3% of the RNs, an acceptable representation for developing conclusions about the data. Nurse satisfaction was measured using the 44-item Index of Work Satisfaction (IWS), a tool that has been widely used since the early 1980’s. Satisfaction was rated on a seven-point Likert scale from 1 (strongly agree) to 7 (strongly disagree). The IWS contained six subscale components: pay, autonomy, professional status (professional self-worth and value), interaction (between RNs and between RNs and physicians), task requirement (time available for patient care and caring), and organizational policies (perception of RN control over work environment). Subscales components were summed to create an overall component total score and averaged to create an overall component mean score. Reliability analysis was done using Cronbach’s alpha.

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Organizational trust was assessed using the 29-item Organizational Trust Index (OTI) in which RNs rated their agreement with statements concerning trust or satisfaction on a five-point Likert scale ranging from 1 (very little) to 5 (very great). The five subscales were competence, reliability, openness and honesty, and concern for employees. The items within each subscale or dimension were summed for a total dimension score and averaged for a mean dimension score. The testing of the OTI showed an overall alpha reliability of .95. The subscales had excellent reliability ranging from .85-.90 (Williams, 2005). Data was analyzed using the SPSS-8 statistical software. Descriptive statistics that included frequencies, means, and standard deviations were calculated for each component of the two surveys. A correlation matrix was calculated to examine the relationships between the six components of nurse satisfaction and organization trust. It showed that organizational trust was significantly and positively correlated with each component of RN satisfaction (Williams, 2005). The focus on a sole organization limits the study. Future studies are warranted and should include HCOs located in different environments that operate in different marketplaces in regard to competition, supply of nurses, and rural verses urban settings. A multiple regression analysis on the data was done to explore the predictive value of the components of job satisfaction on organizational trust with each component entered as independent variables and organization trust being the dependent variable. This analysis produced four significant predictors of organizational trust: professional status, autonomy, organizational policy, and interaction. A linear stepwise regression model was used to identify the most powerful predictors of organizational trust and included policy, followed by interaction and autonomy (Williams, 2005).

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William’s study indicates HCOs with management styles that provide nurses autonomy, which means having control over their work environment in making knowledge-based decisions, will have nurses that are more satisfied and have a higher level of trust in their organization. “Command and control managerial styles and centralized decision making are inconsistent with autonomous practice” (Williams, 2005, p. 209). Professional interactions among peers and between nurses and physicians can be written into policy and included as performance expectations. These must be reinforced because they encourage mutual respect, promote job satisfaction, and increase organizational trust. Nurses represent the largest number of healthcare providers in hospitals and bear the greatest responsible for the quality of care. Nurses deserve optimal practice environments and a trusting organizational culture that supports their efforts. Adequate staffing and HCO support for nursing are key to job satisfaction and reduced turnover rates and as these studies suggest, enhance quality of patient care, satisfaction and positively impact financial returns. Satisfaction and Engagement Surveys Many hospitals evaluate the quality of their health care based on factors that include patient satisfaction data in response to requirements from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or state regulating agencies. Satisfaction of patients and employees is often viewed as a priority and can be a competitive edge in decreasing nursing turnover but surveys are costly. Listening to employee’s and patient’s concerns through satisfaction surveys is one of the most effective ways to define what they want and value in the organization. The average satisfaction survey consists of 150 questions, can take over an hour to complete, and the results can take several months to receive (Fassel, 2001). HCOs that invest in programs to determine how patients and employees evaluate their experiences will possess

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valuable information to make transformational changes in care delivery and services. Understanding the information and utilizing it in the form of an action plan can be a challenge. Many HCOs opt for vendor satisfaction survey programs that include key areas for improvement such as those created by Press Ganey, the Jackson Group, Professional Resource Consultants, the Gallup Organization, and others. Press Ganey (2006) reports HCOs that create a foundation focused on four key drivers (overall organization impression, recognition of employees, employee participation, and a strong senior leadership) will experience improvements in employee and patient satisfaction as well as quality of care. They note the relationship between patient satisfaction, employee satisfaction and quality is interactive. Satisfied employees deliver better care to patients, resulting in greater patient satisfaction and better outcomes. Working for an organization that values patients and delivers exceptional care drives employee satisfaction, loyalty, and retention (Press Ganey Associates, 2006). Flagstaff Medical Center has employed vendor survey programs to conduct community, physician, patient, and employee satisfaction surveys. Community surveys are conducted approximately every five years, physician and employee satisfaction surveys every two years and patient satisfaction surveys are continuous. The last employee survey was completed in 2005 by the Gallup Organization and utilized the Q12 (Appendix A). This engagement survey consisted of twelve questions that were rated on a Likert scale of 1 (least true) to 5 (most true) and took approximately 10 minutes to complete. Measuring employee engagement was desired as the previous employee satisfaction surveys were considered too lengthy, and the confusing results that filled binders arrived months after the survey. These surveys had been used every two years over the previous ten year period.

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The Gallup Organization surveyed a total of 275 RNs. The results showed lower than industry average scores in the areas of RNs connection to the mission of the organization, being able to do their best work every day, and knowing what is expected of them at work. The previous employee satisfaction survey had been done in 2003 by Management Science Associates (MSA), consisted of 122 items (Appendix B) and required approximately one hour to complete. The sampling of organizational results (Appendix C) showed dissatisfaction that was slightly higher than industry mean values regarding administrative trust and caring about employees, manager and departmental communication, benefits, resource utilization, opportunities to participate in organizational-wide and departmental decisions, organizational honesty, relationships with physicians, and having a shared set of values. The FMC continuous patient satisfaction surveys are conducted by Professional Research Consultants (PRC) and done by telephone surveys as a random sample. Those patients that request a survey can have an inpatient (Appendix D), outpatient, or an emergency department (ED) version of the telephone survey mailed to them which is identical to, but not intended to replace, the telephone survey. The number of items on each survey range from 37 on the ED version, to 57 on the inpatient survey. The questions are to be answered as a rating from “don’t know”, “poor”, “fair”, “good”, “very good”, to “excellent”. The results are only calculated for survey items rated as “excellent.” For fiscal year (FY) 2006, 1443 hospitalized patients at FMC were surveyed. The annual excellent percentile rankings for inpatients (Appendix E) had three key drivers: overall teamwork between doctors, nurses and staff; nurses instructions, explanations of treatments and tests; and hospital staff’s courtesy and friendliness. Teamwork excellence for FY2006 was rated as 79.4% but compared poorly to 91.2% for FY 2005 and 92.1% for FY 20004. Nurses’ instructions

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excellence for FY 2006 rated at 90.1% was lower than 96.8% for FY 2005 and comparable to 89.8% for FY 2004. Hospital staff courtesy and friendliness for FY 2006 was rated at 97.2%, which is higher than either FY 2005 at 96.2% and FY 2004 at 94.7%. The overall quality of care excellence rating for FY 2006 was 81.9% when asked at the beginning of the telephone survey and 87.3% when asked at the end of the survey. This compared poorly to the rating of 93.5% at the beginning of the survey in FY 2005 and 87.7% in FY 2004. According to Eula Weaver, FMC specialist, (personal communication, January 15, 2007) overall quality of care had never been asked at the end of the survey prior to the 2006 survey, and it will no longer be asked at the front of the survey. Questions in the 2006 survey regarding nurses rated lower than FY 2005 in overall nursing care, nurses’ communication with patient/family, nurses’ understanding and caring, nurses’ promptness in responding to call bells, and nurses’ respect for patient’s privacy. Overall quality of nursing care for FY2006 was rated 86.9% as compared to 96.2% in FY 2005. Nurses’ understanding and caring for FY 2006 was rated 85.7% as compared to 93.5% in FY2005. FMC has utilized three separate vendors to survey patients and nurses over the last four years. According to Bruce Blankenship, NAH vice president of human resources (personal communication, January 19, 2007), the organization is currently in the process of considering utilizing only one company to conduct all surveys to best capture overall satisfaction and any relational attributes. Timing of surveys could influence the overall satisfaction results and relationships between patient, physician, community, and nursing satisfaction could be investigated.

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The reasons for the dramatic decline in FMC nurse and patient satisfaction scores during 2005-2006 need to be explored. Three potential contributing factors have been identified. The first is that severe cost-cutting measures have been instituted over the last twelve months. Secondly, the March 2004 designation of the model of holistic nursing as the foundation of nursing practice at FMC has not been reinforced. There has been no staff nurse education or implementation of core values and practice definitions within the organization. FMC Central Council representatives, coordinators and directors were responsible to share information on the holistic nursing model with their staff. Even though the holistic nursing framework was selected by a group of 75 staff nurses, it may not have been embraced by the nursing leadership team. Many staff nurses are not even aware of this change or what holistic nursing means. The third potential contributing factor toward the declining satisfaction scores is that the momentum to become a magnet-designated hospital has been delayed. The results of the FMC surveys are in alignment with studies cited above. Both at FMC and across the nation, HCOs need strong leadership that provides decentralized decision-making where administrative leaders listen, are open to employee feedback and encourage employee participation. This can be achieved by providing a culture that assures RN empowered autonomy with an expectation of professional, respectful interactions from both doctors and nurses that is reinforced. Nurses need to feel respected and valued within their HCO with regular recognition and adequate staffing in order to deliver high quality care to their patients. The ability to care is deeply rooted in all nurses. Current Approaches to Decreasing the Nurse Turnover Rates Building healthy work environments that are healing in order to attract, retain and lessen the nursing turnover is not a new idea. In 2004, the Institute of Medicine published, Keeping

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Patient’s Safe: Transforming the Work Environment of Nurses, which determined that the work environment in which nurses’ practice poses a threat to patient safety and that organizational culture in itself is a threat (Institute of Medicine, 2004). The American Organization of Nurse Executives (AONE) has published two volumes dedicated to improving the nursing work environment that is based on a key informant study conducted by McManis & Monsalve Associates. Twenty-one hospitals and 61 individuals participated in the survey contributing experiences, best practices, and lessons for strengthening the nursing work environment. Six key organizational success factors were identified: leadership development and effectiveness, empowered collaborative decision-making, work design and service delivery innovation, values-driven organizational culture, recognition and reward systems, and professional growth and accountability. Eleven work environment improvement initiatives are elaborated upon including: shared governance and collaborative decision making, senior administration support and communication, leadership development and management culture, staff recognition programs, nursing wellness, and preparing for magnet facility designation (American Organization Of Nurse Executives, 2003). The design of magnet hospitals rose out of the awareness that despite the nursing shortage in the early 1980’s, some hospitals were able to attract and retain nurses by creating nursing practice organizations that served as “magnets” for professional nurses. The American Academy of Nursing authorized the original study, Magnet Hospitals: Magnet Hospitals; Attraction and Retention of Professional Nurses (McClure, Poulin, Sovie, & Wandelt, 1983) in the fall of 1981 to identify a national sample of these hospitals and to identify the factors that were related to their success. It was a qualitative, descriptive study based on grounded theory, which was appropriate since the constructs that were to be explicated and measured were changeable and ill-

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defined. Administrative characteristics showed the hospitals that were able to maintain high quality care with adequate numbers of RNs had management styles that were participative, flat organizational structures with decentralized decision making, viewed the quality of the nurses to be as important as the quantity, rarely-used temporary nurses, and reasonable personnel policies. The image of RNs in these hospitals was very positive with nurses being perceived as autonomous, professionally competent, valued and respected. The magnet designation of hospitals began in 1994 by the American Nurses Credentialing Center (ANCC) to recognize excellence in hospitals in four major areas: management, philosophy and practice of nursing services; adherence to national standards for improving the quality of patient care services; support for professional practice and continued competence of nurses; and understanding and respecting the cultural and ethnic diversity of patients, their significant others, and healthcare providers (Burke, 2005). There are currently 223 magnet facilities (ANCC, 2007). The organizational elements of magnet hospitals include knowledgeable, strong leaders that are risk-takers and follow a meaningful philosophy that is made explicit in the day-to-day operations of the organization. The organizational structure is decentralized with a participative management style that encourages two-way communication with active listening. Multidisciplinary decision-making is essential. Collegial nurse-physician relationships receive constant attention and nurturing with an expectation for mutual respect. Staff development, education, and personal growth are considered a high priority. Nurses are viewed as essential, professional providers with the responsibility, authority, and autonomy to provide excellence in health care. Directors of nursing and nursing management are viewed as responsible for developing an environment where high quality healthcare can flourish (American Organization of Nurse Executives, 2003).

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“Professional practice environments, such as those found in the acclaimed magnet Hospitals, all include the elements of nurse job satisfaction that contribute to organizational trust” (Williams, 2005, p. 210). The main goal of magnet hospitals is to create healthy workplace environments from which to attract, retain, and decrease nursing turnover in order to deliver the high level of healthcare that all patients deserve. Integrating holism and holistic care is another current approach to decreasing nurse turnover rates within hospitals by increasing RN and patient satisfaction. Holism is a philosophy more than a specific modality. Holism or holistic care involves caring for patients as a whole, with an awareness of their physical, mental, emotional, and spiritual dimensions and needs. This approach is not a new idea as it originates as far back as Florence Nightingale, the founder of modern nursing. Nightingale was a scientist, statistician, and a mystic. Even Hippocrates, the father of western medicine, was both a physician and a priest (Thornton & Gold, 1999). Jean Watson, PhD, a contemporary holistic nursing theorist, promotes caring as the essence of nursing. She states that human caring has been increasingly deemphasized in the healthcare system and that caring of self is a prerequisite to caring for others (Neil, 2002). Holism has gained international appeal. There are many articles from around the globe that identify the integration of holism, holistic care, and holistic nursing into hospitals and healthcare organizations. Hau states that the integration of holistic nursing is impeded by a pragmatic healthcare system in Singapore, Australia and the United Kingdom (Hau, 2004). Americans spend millions of dollars annually on holistic therapies, capturing the attention of the White House (Donnelly, 2003). In 2000, this growing interest in complementary and alternative therapies resulted in the formation of the White House Commission on the Complementary and Alternative Medicine (CAM). President Bush appointed 20 commissioners,

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representing varied traditional and nontraditional health care professionals, to develop recommendations regarding this trend. The need for research to determine efficacy of holistic therapies, effects of patientpractitioner relationships on therapeutic outcomes, individualization of treatments, and modalities and practices the improve self-care and promote well-being were the recommendations that resulted. The first recommendation is intended to protect the public and legitimize CAM. The last three recommendations validate professional nursings belief of the importance of caring relationships in producing optimal health outcomes, stressing the uniqueness of individuals, and of emphasizing self care. The National Institutes of Health currently runs a $100 million program to fund studies on alternative care. The American Holistic Nurses Association (AHNA) was founded in 1980 by Charlotte McGuire, who worked at Flagstaff Medical Center for five years during the 1990’s. The main AHNA headquarters, or heartquarters as it is referred to, is located in Flagstaff, Arizona, just a few blocks from FMC. The AHNA defines holistic nursing as ‘nursing practice that has the enhancement of healing of the whole person as its goal” (Dossey, Keegan, and Guzzetta, 2005, p. 86). The mission of the AHNA is to “unite nurses in healing” (Frisch, Dossey, Guzzetta, & Quinn, 2000, p. xv). Holism is derived primarily from the natural systems theory and work of von Bertalanffy. It provides a process for comprehending the interconnectedness of natural structures in the universe. From the level of subatomic particles to the universe, changes in any one part of the hierarchy affects all other parts simultaneously (Dossey et al.). The traditional biomedical Western view of disease, sometimes referred to as allopathic, usually begins at the systems level

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and stops at the molecular level. According to natural systems theory, disease can originate in a disturbance at any level from the subatomic to the suprapersonal then affects all other levels. The holistic model is based on the bio-psycho-social-spiritual dimensions, which are interdependent and interrelated, and provides the most comprehensive guide to treating the whole patient (Table F1). According to Dossey & Guzzetta (2005): Two major challenges in nursing have emerged in the twenty-first century. The first is to integrate the concepts of technology, mind, and spirit into nursing practice; the second is to create and integrate models for health care that guide the healing of self and others. Holistic nursing is viewed as the most complete way to conceptualize and practice professional nursing. (pp. 8-9) Caring is central to holistic nursing. The therapeutic role of the nurse includes making caring connections with their patients through being fully present and authentic. Peplau noted that the nurse patient relationship is the crux of nursing and postulated that it influences patient outcomes (Haggerty & Patusky, 2003). Jean Watson describes the caring moment/caring occasion as a situation where the nurse and client come together in a transformational encounter, leaving both the nurse and client changed in a healing way (Dossey et al., 2005). Recommendations from the Institute of Medicine encourage nursing care that is based on continuous healing relationships and customized according to the patient’s needs and values (Institute of Medicine, 2000). For traditional nurses, the lack of time for making caring connections can leave them dissatisfied. Holistic nurses are more self actualized and aware that these caring moments/caring occasions are not time intensive. Williams conducted a qualitative study of medical-surgical nurses in a hospital on the east coast of the United States and found that although they did not consider themselves holistic

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nurses, they were aware of the multidimensionality of healing and the importance of forming caring relationships with their patients. These nurses identified higher levels of frustration and self-imposed limitations than holistic nurses who “have tapped into a source of strength and confidence that added creativity and vitality to their nursing work” (Jackson, 2004a, p. 127). McCance (2003) conducted a qualitative research study in Ireland utilizing a hermeneutic approach to elicit stories related to patient’s experience of caring that was selected incorporating a narrative method. Interviews of patients in their homes shortly after discharge from the hospital revealed that nurse attentiveness, respect, and touch created a feeling of well-being, increased patient satisfaction, and had a positive effect on the environment. Work environments that are healing and nurturing for staff and patients will enable HCOs to attract and retain nurses and reduce nurse turnover. Creating holistic environments has also received international attention. Prince Charles has established a new initiative to build holistic hospitals that are more sensitive to the needs of patients to assist their healing. The Prince of Wales stated, “As I think Florence Nightingale acknowledged, all medical healing ultimately involves processes whereby something from outside is brought to the patient so that he or she can make their own inner step that can trigger recovery” (The Holistic Centre, 2006, p. 1). Janet Quinn, PhD, RN, has offered healthcare executives an answer to retaining and attracting nurses by creating healing environments in which nurses can truly care for patients (Quinn, 2002). She suggests combining the best attributes of magnet hospitals with principles of holism. Relationship-oriented care and mind-body-spirit orientation would be included in developing “Nightingale units,” that are designed to sustain, nurture, and value nurses at the hospital nursing-unit level. These units would provide nurses autonomy, adequate staffing, as

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well as the resource of clinical nurse specialists and nurse practitioners to serve as primary care clinicians. Nightingale unit nurses would attend self-care classes along with other staff development and patient care programs. The goal would be to maintain a healthy environment for healing for all who enter the unit. “Caring-healing modalities,” a form of complementary and alternative medicine, such as healing touch, massage, meditation, acupressure, and music therapy would be offered to patients alongside of traditional allopathic treatments. This strategy holds the potential for economic benefits as many patients are already paying billions of dollars for these therapies outside of the hospital setting (Jackson, 2004b). Planetree is a nonprofit consulting organization that works wit hospitals and other facilities to develop and implement patient-centered care in healing environments. The Planetree movement began in 1978 when Angelica Thieriot had a negative hospital experience in which her mental, emotional, social and spiritual needs were not addressed. A triangle design that addresses the needs of patients, family members, and staff defines the Planetree Model. It is characterized by a patient-centered, value-based holistic approach that cultivates healing of mind-body-spirit (Planetree, 2006). The Planetree philosophy is based on dignity, compassion and humanity. “It is about recognizing patients’ humanity and providing them with the most technically advanced medical care in therapeutic environments that promote healing through information, education, architecture, design, scents, sounds, and human interactions” (Frampton, 2005, p. 82). The first Planetree facility was a single 13-bed unit at Pacific Presbyterian Medical Center in San Francisco which incorporated a variety of design elements created to eliminate stressors that can diminish the healing process. Rooms with views of gardens, pleasing wall colors, music

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therapy, nourishing food, open visiting hours, minimizing noise and open architectural designs with kitchenettes and open spaces for patients and family members, or care partners, are examples of the Planetree Model. Planetree is utilized by more than 100 acute care hospitals worldwide and is the most widely practiced patient-centered care model in the United States. In 2007, Planetree will rollout a designation process for patient-centered hospitals. Planetree hospitals report increased patient and staff satisfaction, greater patient loyalty, reduced staff turnover, and a healthier bottom line. Over the past few years, the number of medical centers with alternative clinics or departments has increased to over 100 with Duke, Stanford, New York’s Beth Israel, and the University of Colorado being among those incorporating holism. Abbott Northwestern Hospital, a 621-bed nonprofit facility in Minneapolis, Minnesota that employs 2000 nurses, developed the largest hospital-based holistic program in the country (Knutson, 2006). In 2002, the administration supported a movement to bring a healing environment with an integrative care approach to the hospital and in 2003, the “Institute for Health and Healing” was opened. The role of holistic nurse clinician was established at Abbott Northwestern Hospital which has now been renamed and fine-tuned into the title of integrative medicine (IM) nurse clinician. There are currently six full-time IM nurse clinicians assigned to specific specialty areas. Their role is 50% direct patient care, where they perform holistic nursing assessments, provide CAM, and educate patients and their families regarding self-care. The remainder of their time is spent educating and training staff nurses to move toward the goal of full integration of holistic nursing care at the bedside. The institute opened an outpatient integrative medicine clinic in 2004, and in 2006 a research partnership with the Samueli Institute was developed.

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The Whole-Person Caring Transformational Healthcare Leadership Program is a holistic educational curriculum that is a current and dynamic approach to improving the workplace environment designed to decrease nurse turnover rates and increase nurse and patient satisfaction. It is an interdisciplinary model for hospitals and HCOs based on the works of nurse theorists Jean Watson, Florence Nightingale, and Martha Rogers. It is a valuable tool for the establishment of a stable foundation to address current and emerging challenges, including a lack of meaning and purpose in organizations. The Model of Whole-Person Caring (WPC) is energy-based and views people as spiritual beings that are in continual mutual process with their environment (Table F2). Rather than being based on a business model that embraces a biomedical perspective, the core of this model is focused on creating a healing and nurturing environment for employees and patients. Through the six key components, a paradigmatic shift in how we perceive ourselves occurs that is necessary to change the way we care for each other. The key components are: sacredness of being, therapeutic partnering, self-care and self-healing, whole person nourishment, transformational healthcare leadership, and caring as sacred practice (Thornton, 2005). The foundation for leadership, in the Whole-Person Caring Transformational Leadership Program, is based in the spiritual-energetic realm which results in an organization that is more caring, empathetic, and empowering for its employees. The educational program is a three-phase interdisciplinary, educational series that begins with a two-day seminar that covers the key components with application to the work environment. This is followed by a six to nine month personal integration phase that is a self-paced independent program. A mentor is available to help guide participants, answer questions, and helping them to integrate the key components into their lives. This is supplemented with monthly two-hour classes. The last phase is a two-day

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seminar that focuses on integrating the key components into their organizations and daily work lives. Three Rivers Community Hospital in Grants Pass, Oregon integrated the WPC Transformational Leadership Program in 2001 at a critical time when two hospitals merged and morale was very low (Thornton, 2004). A healing environment and a change of culture were needed. Following the program’s institution, Press Ganey patient satisfaction survey results increased to 94% from average hospital-wide scores in the low 80th percentiles. Their RN turnover rate reached a low of 3%, compared with a national average of 18% at the time (Thornton, 2005, p. 114). This translated into a considerable financial savings for the hospital. The staff was revitalized, employee’s integration of organizational values increased, and there was an improvement in workplace morale. A healing environment had been created and was sustained. In 2004, Three Rivers Community Hospital received the Fetzer Institute Norman Cousins Award and the Oregon Association of Hospitals and Health Systems Award for Professional Excellence in Healthcare Leadership. Current approaches to decreasing nursing turnover involve building healthy work environments that give emphasis to caring and healing. Magnet designation of hospitals, integrating holistic care, Nightingale units, the Planetree movement, alternative clinics within hospitals, and education programs, including the Whole-Person Caring Transformational Healthcare Leadership Program, have been shown to increase nursing satisfaction and decrease nurse turnover rates. Theoretical Constructs Related to Problem Resolution According to Watson, nursing is grounded in the philosophy and science of human caring (Watson, 1979). Upholding these caring values in daily practice helps transcend the nurse from

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“just doing the job” to that of a gratifying profession. Watson’s Caring Theory not only allows the nurse to provide compassionate care to alleviate suffering and to promote their dignity and healing, but can also contribute to expansion of the nurse’s own actualization. Watson is one of the few nursing theorists who considered the caregiver as well as the cared-for. In her latest book, Caring Science as Sacred Science (Watson, 2005), she implores nurses, and all health professionals, to search deeper spiritual meanings for the nature of our work and life purpose and to consider the sacredness of our caring-healing professions. Over the last twenty-six years, her theory has continually evolved, but it has always remained holistic. The major elements of Watson’s theory are the transpersonal caring relationship, the caring occasion/caring moment, and the ten clinical caritas processes (formerly carative factors). The transpersonal caring relationship characterizes a deep kind of human care relationship that depends on the nurse’s moral commitment to protecting and enhancing human dignity as well as the deeper/higher self, the nurses caring consciousness communicated to preserve and honor the embodied spirit (not reducing the person to the moral status of an object), and the nurse’s caring consciousness and connection having the potential to heal since experience, perception and intentional connection are taking place. Transpersonal refers to the human-to-human connection that exists beyond the ego self and connects with the more spiritual, even cosmic connections of the universe (Watson, 2005). Watson’s caring occasion/caring moment occurs when a nurse and another person come together with their unique phenomenal fields and a juncture for human caring is created (Watson, 1999). Phenomenal field refers to the totality of the human experience which includes feelings, thoughts, goals, expectations, meanings, spiritual beliefs, and bodily sensations based on one’s past, present and future. Watson stresses that the intentionality and the consciousness of the

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nurse affect the whole field and the experience (J. Watson, personal communication, February 7, 2007). The caring moment can influence and affect the cared-for and the caregiver and becomes transpersonal when it allows for the presence of the spirit of both. When this occurs, the caring moment is instantaneous and does not require long periods of time. Lack of time to create meaningful relationships with patients is one of the most frequently cited dissatisfactions among nurses. Watson’s caring occasion/caring moment theory brings to life the depth that spirituality can bring to relationships and to one’s existence. Caritas is Greek, meaning to cherish and to give special loving attention. Watson’s ten clinical caritas processes are: (1) to practice loving kindness and equanimity within the context of caring consciousness, (2) being authentically present, and enabling enabling and sustaining the deep belief system and subjective life world of self and the one-being-cared-for, (3) cultivation of one’s own spiritual practices and transpersonal self, going beyond ego self, opening to others with sensitivity and compassion, (4) developing and sustaining helping-trusting, authentic caring relationship, (5) being present to, and supportive of, the expression of positive and negative feelings as a connection with deeper spirit of self and the one-being-cared for, (6) creative use of self and all ways of knowing as part of the caring process; to engage in artistry of caring-healing practices, (7) engaging in genuine teaching-learning experience that attends to unity of being and meaning, attempting to stay within others’ frames of reference, (8) creating healing environments at all levels (physical as well as non-physical), subtle environment of energy and consciousness, whereby wholeness, beauty, comfort, dignity, and peace are potentiated, (9) assisting with basic needs with an intentional caring consciousness, administering “human care essentials,”

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which potentiate alignment of mindbodyspirit, wholeness, and unity of being in all aspects of care; tending to both the embodied spirit and evolving spiritual emergence, and (10) opening and attending to spiritual-mysterious and existential dimensions of one’s own lifedeath; soul care for self and the one-being-cared-for. (Watson, 2001, p 247) Watson defines the person as a being-in-the-world who holds three spheres of being (existence) that encompass a mind, body and spirit, a unity that is influenced by the concept of self and is free to make choices (Watson, 1988). She believes that spirituality upholds a foremost importance in nursing and that care of the soul is the most powerful aspect of the art of caring (Watson, 1997). Her view of health is that is corresponds to a person’s harmony or balance, within the “bodymindspirit”, and is related to the degree of congruence between the self as perceived and the self as experienced. Watson separates caring from curing which delineates nursing from medicine. This is necessary to classify the body of nursing knowledge as a separate science. Watson’s definition of nursing has also evolved, identified as an art and a science with caring being the essence and characterized by being-in-relation with one’s self, others, and the environment. Her theory of human caring is humanistic, holistic, and relationship-centered with an emphasis on existentialphenomenological and spiritual factors (Neil, 2002). There are many common principles between the Model of Whole Person Caring (WPC) and Watson’s Caring Theory. Both are holistic with integration of body, mind, and spirit. They are relationship-centered with a value on therapeutic partnering and transformational in that growth of self and others is promoted. Ongoing development of one’s own meaning and purpose in life encouraged, focusing on care of self and self-healing as essential to caring for others. Watson’s Caring Theory and the model of WPC are based on the energetic realm with

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integration of spirituality, viewing the act of caring as sacred practice. Healing is delineated from curing. Cultivating a deep respect for self and others, enhanced creativity, and recognizing self and others as sacred are common to WPC and Caring Theory. Finally, this model and theory have an emphasis on exploring the meaning and source of symptoms, as illness is viewed as an opportunity to reconnect with holistic roots in order to explore and shift lifestyle patterns. Jean Watson’s Caring Theory offers strength to the integration of holism into the hospital setting by reinforcing the need for deep, sacred caring between nurses and their patients. Nurses, through developing their own intentional caring consciousness, can enhance the healing environment which will bring satisfaction back to the profession and decrease nursing turnover. Implementation and Evaluation Intervention In order to minimize the problem of nurse turnover at Flagstaff Medical Center (FMC), a proposal is being presented to institute the Whole-Person Caring Transformational Healthcare Leadership Program within one medical-surgical unit. Participants will include an interdisciplinary team composed of nursing, medicine, administration, and ancillary staff that function on the chosen medical-surgical unit. Completing the 30-member team will be the chief nursing officer (CNO), the medical-surgical director and the unit manager. Thirty staff members from outside the chosen medical-surgical unit will serve as a control group. Pre and post-intervention surveys of patient satisfaction and employee/nurse satisfaction will be used to evaluate the effectiveness of the program. Nurse turnover will be computed prior to and following completion of the program by the human resource department utilizing the updated Nurse Turnover Cost Calculation Method (NTCCM).

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Implementation The Whole-Person Caring Transformational Leadership Program is a three-phase educational curriculum that consists of an initial two-day seminar and a six to nine-month selfpaced independent program guided by a mentor that concludes with a second two-day seminar. The initial implementation process will involve assessing the organizations ideology and culture to assure congruency of this program with the established culture; eliciting support of key people, involving everyone, and presenting the program to the administrative team. JCAHO standards acknowledge a patient’s right to spiritual care and the HCO’s responsibility to meet these needs, though wide latitude for the provision of such needs exists (LaPierre, 2003). In 2004, FMC adopted a model of holistic nursing practice as a framework for providing the spiritual needs of patients. In this context, spirituality is defined as “a unifying force of a person; the essence of being that permeates all of life and is manifested in one’s being, knowing and doing; the interconnectedness with self, others, nature, and God/Life Force/Absolute Transcendent” (Appendix F). Spiritual integration adds a transcendent dimension that can transform the workplace into an environment that is more relational, collaborative, receptive, and less controlling (Hume, Richardt, & Applegate, 2005). Spirituality involves more than just religious beliefs and involves the capacity to relate to something larger than self and the search for meaning, purpose and direction in one’s life. Assessing the organizations ideology and culture is a crucial first step to assure congruency of this spiritually-based program. Because spirituality is often synonymous with religion, a viewpoint many consider a private matter, identifying the beliefs of the sample population presents an opportunity to define spirituality within the context of the WPC Model and avoid any preconceived bias that my hinder the process. The assessment will also identify knowledge

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deficits with respect to the holistic nursing model and serve as the framework for an educational program for the staff Eliciting support of key people and hospital-wide involvement is crucial to the success and continued support of the program. Key people include upper management as well as employees from all areas who hold values and beliefs similar to WPC. There are many nurses and other staff that demonstrate a deep caring attitude and lead others utilizing principles of transformational leadership. These people are often inspiration to others around them and should be easy to identify and integrate into a core group. A permanent change in the prevailing culture will require a long-term commitment by employees, management, administration and the governing board, so everyone needs to be involved. The Model of Whole-Person Caring is all-inclusive—everyone needs to be involved. Most healthcare practitioners want to care fully and deeply for their patients but may not know the steps to accomplish this. Since this model stresses self-care as being a prerequisite to caring for others, and the majority of staff has never been taught ways to do this, talking about this component of the program should create interest and generate involvement. The last step of the initial implementation process is presenting a plan to the administrative team, acknowledging a vision that is designed to change the culture of the organization. This proposal will be delivered by the creator of the WPC Transformational Leadership Program. A thirty-minute presentation utilizing PowerPoint will identify the key components of the holistic educational program. To foster support, the Three Rivers Community Hospital program and outcomes will be presented. Since the average cost to replace a RN within a HCO can range from $62,100 to $67,100, the cost to FMC of a 15.68% turnover rate translates to an estimated cost of $4,843,800

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to $5,233,800 each year. By decreasing the RN turnover rate by 1%, or five nurses, FMC would save $310,500 to $335,500 annually. The cost of this program, with the four days of workshops and monthly two-hour meetings for nine months during the mentor-guided self-paced independent study phase, is approximately $50,000 which includes the cost of the program and participants time calculated at $30.00/hour. This amount would easily be recovered by a 1% reduction in RN turnover. Once administrative approval has been obtained, the main phase of the implementation can proceed. This will involve participant selection, implementing satisfaction surveys, and beginning the educational program. Selection of the specific medical-surgical unit will be made by the CNO and medical-surgical director. Participants will be chosen by the CNO and medicalsurgical director, the vice-president of medical staff (physician), other department directors, and frontline staff. The NAH vice-present of human resources will have selected the new assessment survey tools from one vendor. He will also ensure that predetermined data will be gathered. This will include information with respect to employee’s perception of value, respect, caring, autonomy, and likelihood of staying employed for the next two years. Patient satisfaction items will include perception of nurses caring, therapeutic partnering, respectfulness and attention to spiritual needs. Content validity will be established by a team of nurse managers and the CNO. Instrument reliability/validity will be assured by the vendor. A report of the current nurse turnover rate will be obtained from the human resources department. The assessment surveys will then need to be conducted. Implementation of the first phase of the program will involve making arrangements for the speakers, rooms, and assuring that participants have the days off work which will be arranged by

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their supervisors or unit managers. FMC has an educational center that can easily accommodate fifty people. The two-day workshop is mostly experiential with a small didactic component. Group sharing will be encouraged and a variety of exercises will be integrated. The first day will start with explaining the Model of WPC including how it relates to other theories. The importance of relationships, how to foster quality relationships and developing therapeutic partnering with patients and within the healthcare team will be discussed with examples and exercises. The topics of stress and burnout will begin the section on self-care and self-healing along with coping with stress and a discussion of effective leadership strategies for dealing with chaos in the workplace. A guided relaxation experience will be included at this point. Exploring self-caring and self-healing practices will include movement, meditation, visualization, affirmation, imagery, yoga, and breathing exercises. The second day of the initial phase of the program will begin with whole-person nourishment that focuses on optimal diet, conscious eating practices, and guidelines for creating a healthier body followed by an imagery experience and journaling. Energy-based science and healing and exploring energy from various theories, including Watson’s caring theory, will be offered. Additionally, spirituality will be viewed from a science background with a review of complementary and alternative modalities. Transformational healthcare leadership will be presented including the importance of attitude, signs of mature leadership, and cultivating the whole-person leader within followed by an exercise in creating a personal mission statement. The final component of this workshop is WPC as sacred practice that includes aspects and essentials of spiritual health, the difference between spirituality and religion, effects of prayer, foundational components and related theorists of caring as sacred practice. Florence Nightingale

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and Jean Watson’s work will be highlighted. This will be followed by the effects of caring, the role of caring and love in the healing process, caring moments, listening, and communicating from the heart. The workshop will conclude with a closing circle experience. The second phase of the WPC Transformational Leadership Program is a mentor-guided six to nine-month self-paced independent program with monthly two-hour classes or gatherings for participants to share their experiences and meet as a group. Weekly journaling is an expectation of all participants. Six self-paced, independent modules will be provided to include additional information and awareness of WPC. Each of the modules has a work section that is collected and reviewed by mentors when completed. Individual discussions can be arranged or questions can be discussed as a group in the monthly gathering. The FMC mentors will be nurses that are either basic or advanced certified holistic nurses (HN-BC or HN-AC) or nurses that have an extensive knowledge of holistic nursing. This group will be hand-selected by the CNO and director of medical-surgical nursing with assistance by the certified holistic nurses. Certification is accomplished through the Holistic Nurses Certification Corporation, the testing agency of the American Holistic Nurses Association (AHNA). There are a group of 12-15 holistic nurses from FMC that meet monthly at the AHNA heartquarters. FMC has a policy that compensates mentors and preceptors financially and this will be offered as an incentive. Nurses that complete the program will be offered to mentor other participants in future programs. The third and final phase of the program is a two-day workshop that begins with a review the six key components of WPC so that they can experience the breadth of their own personal holistic journeys. The afternoon of the first day is dedicated to developing new personal mission statements and experiential exercises. The morning of the second day begins with a group

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discussion of how WPC has been integrated into their personal lives, work and the organization followed by a group exercise in how this can be sustained over time. They are asked to record their ideas on post-it notes that are then placed on the walls to consider and reconsider all ideas, and then rearrange them into common themes. The participants are divided into groups to demonstrate their learning as presentations in the afternoon. Each group of five participants are encouraged to be creative through designing skits, writing songs, reciting poetry, reading from their journals or presenting case studies during the last afternoon of the course. Certificates of completion are presented and hugs are exchanged. Evaluation Evaluation of the WPC Transformational Healthcare Leadership Program is accomplished through a tool used to assess program formatting, speakers, and ease of application of the six program components into practice. This will be based on a Likert scale of 1 being the least effective and 5 being the most effective. This will be created in collaboration with a psychometrics expert. One month later the post-program patient and employee satisfaction surveys are conducted with the identical survey tool that was utilized prior to the WPC program. These surveys are taken by the 30 participants, the 30 staff members that served as a control group and the patients from the medical-surgical unit that the RNs were selected from. The satisfaction survey vendor will gather and analyze results. A psychometrics expert will be consulted to review the data. This information will be disseminated to FMC administration, the CNO, the medical-surgical director, coordinator, staff, and community. The implementation of the Whole-Person Caring Transformational Leadership Program at Flagstaff Medical Center offers a current, educational approach to decreasing the nursing

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turnover rates by integrating holism into the hospital setting. There are many necessary steps that must be taken to assure success of the program. Support from administration and key people is essential. The educational workshops with the mentor-guided independent study allows for new ways of thinking to transform the prevailing culture into a holistic, caring and healing workplace. Evaluating nurse and patient satisfaction will confirm these positive changes and document the decrease in nurse turnover. Conclusion Nursing turnover is an enormous human resource and financial problem for our nation’s healthcare organizations. It creates instability in the workforce that threatens the healthcare quality and safety of our society. RNs experience a lack of respect and autonomy and feel undervalued, hampering their ability to provide compassionate, relationship-centered caring. Nurses have become task-oriented and need support and education to reconnect with values and means that support health and healing for them and their patients. Decreasing the dissatisfaction of nurses by building healthier work environments can be accomplished through Magnet designation of hospitals or integrating holism into the hospital setting through Nightingale units, the Planetree Model, designated holistic departments, and embracing holistic theories or models. The Model of Whole-Person Caring integrates holism and creates a shift in culture by infusing spirituality into the workplace to offer a deeper meaning into healthcare organizations. It offers shared values and a united common vision based on caring and healing. The WPC Transformational Leadership Program is a superior choice for Flagstaff Medical Center as it has a proven track record of lowering nurse turnover, increasing the satisfaction of both RNs and patients, with results that can be sustained over time. It is based on Watson’s Caring Theory

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which integrates holistic principles. It creates a healing and nurturing environment where both interdisciplinary staff and patients feel cared for, respected, and valued with relationships that are mutually beneficial and healthy. Whole-Person Caring promotes self-care concepts so that each staff member can bring their best to work each day. This model builds a unified vision that will align employees around shared values yet is practical, operational and engaging. Finally, it creates a “spirited” workforce that is characterized by creativity, enthusiasm and integrity. Caring and healing are the essence of nursing and all healthcare professions. When we forget these critical components for ourselves and others, disharmony and illness result. “It is when we include caring and love in our science, we discover our caring-healing professions and disciplines are much more than a detached scientific endeavor, but a life-giving and life receiving endeavor for humanity” (Watson, 2005, p. 3).

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