How a Burn and Wound Clinic Improved Staff Nurse Retention Through Peer Interviewing

Facing burnout, a lack of autonomy, inadequate facilities and other issues, nurses frequently leave their wound care facilities. Using a peer interview process for hiring helped these authors forge a united and efficient team, as well as achieve facility compliance at their burn and wound clinic. 

In recent decades, health care administrators and nurse managers have been challenged with identifying qualified candidates for patient care positions and retaining these personnel. The entire process of onboarding the right candidate requires time, money and resources, and a top-down managerial approach is not always accepted or successful. Peer interviewing has emerged as a hiring best practice that helps lower the cost of recruitment, decreases the time lost in screening and interviewing potential new hires, and improves employee morale.

During a critical time of growth and the development of a large, advanced burn and wound center, the authors adopted this approach to distribute resources and save time and money. After implementing a peer interview process, retention turnover rates improved from 46% to 8%, which was well below the 17% facility goal. This outcome was significant because it not only helped us achieve facility compliance, but also resulted in a productive, cohesive team.   

For more than 20 years, experts have predicted a shortage of skilled nurses in the United States. This shortage—along with the various negative consequences that coincide with it—has turned out to be an indisputable truth we now face.  

Various factors have been cited as contributing to the nursing shortage, some of which include the aging registered nurse workforce, the decreased supply of nurse educators, declining enrollment in nursing schools, and a changing work climate involving increased acuity in most hospitals.¹ In addition, the current and ongoing demands of COVID-19 have created larger challenges for the nursing workforce.

During drastic times, nurses may develop overwhelming feelings of burnout, work in environments with an inadequate number of staff to meet acuity needs and feel as if they lack the autonomy to influence or impact change. Because of this, nurses frequently leave their jobs, and younger nurses who may have once considered a career in nursing do not end up choosing a nursing career path. This shortage continues to impact health care delivery on a large scale and makes it incumbent on nursing leaders to identify and define controllable aspects of nursing turnover, then adapt best practices to help overcome the challenges inherent to nurse turnover.

Murff and DeFer identify uncontrollable nurse turnover as it relates to retirement, moving from an area, and failure to return from leave.² Controllable nursing turnover is related more to attendance issues, inappropriate conduct, violation of company policy, resignation for dissatisfaction with the hospital, mutual consent, and falsification of records.² One could even argue each of these controllable issues stems from a basic dissatisfaction with the job overall.

While many of these issues might create negative impacts not even mentioned here, the most immediate impact and challenge was retaining nursing staff during a time of extreme growth and change in a busy advanced wound and burn care clinic. To achieve this, best practices were instituted that fostered autonomy, self-governance, trust, and commitment to the organization, which, in turn, helped develop a strong nursing services culture while building a reliable team. One best practice—peer interviewing—served as a successful managerial approach to change a process that resulted in improved nurse retention rates.

How Peer Interviewing Works

This nursing quality improvement effort coincided with a time of growth and expansion in an expanding advanced wound center. Specifically, the number of treatment areas increased from 20 to 37 rooms while the average number of wound clinic admissions increased as well (Figure 1). Certainly, it was desirable to keep as much staff as possible through this challenging time, but it was also necessary to hire additional staff to meet the needs of our growth and expansion.  

The interview process. Because time was crucial during this process, the three-peer interview team of registered nurses decided a one-stage, face-to-face interview was the best approach whenever possible. If a potential nurse interview candidate was from out of town, however, an introductory phone interview was conducted first and was followed by a face-to-face encounter. The selected interview team, which was composed of employees who demonstrated advanced skill levels and job competency, completed corporate training that taught them how peer interviewing was conducted and educated them on the expected guidelines. Varying experiences and backgrounds were considered important qualifications for the team since high performers were more likely to identify other high performers during the process. It also ensured a good mix of employees was present when conducting the interviews.

In addition to the interview team, a structured interview guide was provided to offer standardized questions from various categories, including patient focus and time management, multitasking/stress tolerance, attendance, self-control/stress tolerance, attention to detail, and flexibility/adaptability.³ The questionnaire was developed to be customizable so the team could ask questions and pose direct scenarios that were more realistic to the actual work environment. Customizing at least part of the structured interview guide ensured a selection was made for the individual who best fit our clinic, allowed for the candidate’s skills and attitude to be assessed more readily, and made his/her personal reasons for wanting to join the team more apparent. The interview candidate was encouraged to ask questions of the interview team as well so he/she could gain a better understanding of the work environment and demands of the job. To that end, nurse managers participated in the interviews to ensure the work schedule was shared and explained, and the candidate was given a tour of the clinic. For a final selection and job offer to be made, the team had to be unanimous in its decision.

Hiring. After a candidate was hired, he/she was provided a one-week, mandatory hospital orientation then assigned to a peer preceptor for training. Dedicated preceptorships have often resulted in increased critical thinking and lower stress levels among staff and have ultimately been shown to contribute to better nurse retention.⁴ These are all traits that were desirable and necessary to maintain better workflow processes and patient outcomes and to retain newly hired staff.

Training with a preceptor occurred over a two- to three-week period and consisted of personal, one-on-one input and training related to the clinic process. Considering the volume of patients who were seen daily and how essential it was for care to remain standardized among all staff, it was crucial to give the preceptorship element of onboarding an appropriate amount of time and attention. At the conclusion of the preceptorship, new employees were gradually assigned patient rooms on their own but remained close to their preceptor for support as questions and/or challenges occurred. In addition, although the newly hired RNs were generally ready to work independently, we found the supportive environment and exposure to positivity from those precepting played an integral role in whether new employees stayed with the company.    

Since implementing the peer interview process, preceptors among staff members have been readily available, which reflects how vested the staff are in the newly hired employees. RN peer interviewers own the process and realize their input is an integral part of acquiring a new team member.   

Leadership. The literature reveals retention and job satisfaction among nurses are linked to leadership style and approaches to managing staff.^5–10 Other sources indicate that a positive practice environment in a clinical practice setting contributes to nurse retention.^11,12 Sources also indicate that nurse managers and nursing administrators have the responsibility to determine which practices create these desired outcomes.^11,12 Moreover, a multidisciplinary approach to care is credited with benefiting patients, providers, and health care systems across many settings.^13–16  

The approach taken with this project combined purposeful nurse manager leadership with acknowledgement and support from various levels of clinical staff including, but not limited to, the unit medical director, surgical and wound care staff, and mid-level practitioner staff. This approach allowed for work to continue where gaps might have existed during times of interviewing and on high-volume days when limited staff was available, and it resulted in overall support and consideration for the processes being implemented.  

During times of high census and low staffing—and in this case, physical growth and expansion—nurse managers often bore the burden of stress and burnout. Maintaining a multidisciplinary approach cultivated teamwork and a commitment to goals, and it also helped provide nurse leaders with a reprieve so that tending to the needs of the staff was not so cumbersome when facing daily challenges.    

How Peer Interviewing Improved the Wound Clinic

Prior to the start of this project, annual rolling turnover rates were at a one-time high of 46% with a facility goal of 17%. Clearly, swift and successful intervention was required. Renovation of the existing clinic was ongoing, patient admissions were steadily increasing, and the demand to fix the problem loomed large (Figure 1). The process for peer interviewing was established as a best practice approach by the nurse managers well before it became mandated across the facility and was a proactive measure based on need.  
Within a year of implementing peer interviewing, rolling turnover rates dropped below 8% (Figure 2) and after that fell to 0% for at least 3 months (Figure 3). The only outlying increase in turnover rate during that time occurred when a nurse moved out of town, which, as cited earlier, is an uncontrollable nursing retention challenge. The resulting increased retention rate was reflected in a staff that demonstrated nursing culture appropriate and acceptable to the organization, dedication to their job performance and roles, and demonstrable actions of nursing empowerment. Patient care outcomes were exceptional given the demands surrounding this now cohesive team not only in terms of volume, but also in the demands of physical building and reconstruction taking place on a daily basis.  

Conclusions

Utilizing a peer interview process for hiring helped a newly expanded advanced burn and wound clinic achieve not just facility compliance, but a productive, cohesive team as a result. This outcome is evidenced by the ongoing retention of the original staff and continued participation in the peer interview process by the selected staff. In support of this, employee engagement surveys have increased from 66% in mid-2018 to an all-time high of 78%.¹⁶

Given the autonomy to contribute and be an active part of governance creates a positive work environment that empowers nurses and results in long-term staff retention. A multidisciplinary approach is recognized as essential in providing the support nurse managers need when implementing the processes that achieve these outcomes.  

There are some special considerations and limitations. It is noted that peer interviewing may not be the best approach in every given situation. For example, interview teams may experience problems when there may be more than one qualified candidate but only one open position.¹⁷ Other disadvantages or challenges that might be an issue and include a loss in production time due to employees being away from their job during the interview process, and the intimidation factor for a potential employee when a panel of several people interviews them.¹⁸

Kathleen Prestifilippo, RN, BSN, WCC, is the Director of the Outpatient Burn and Wound Center and Hyperbaric Department at Doctors Hospital of Augusta in Augusta, GA.

Emily Webb, RN, BSN, WCC, is the Clinical Supervisor for the JMS Advanced Wound and Burn Clinic at Doctors Hospital of Augusta in Augusta, GA.

Fred Mullins, MD, is affiliated with Burn & Reconstructive Centers of America in Augusta, GA.

Shawn Fagan, MD, is affiliated with Burn & Reconstructive Centers of America in Augusta, GA.

Zaheed Hassan, MD, is affiliated with Burn & Reconstructive Centers of America in Augusta, GA.

Bounthavy Homsombath, MD, is affiliated with Burn & Reconstructive Centers of America in Augusta, GA.

Beretta Craft-Coffman, PA-C2, is affiliated with Burn & Reconstructive Centers of America in Augusta, GA.

Cynthia Currington, RN, BSN, is affiliated with Doctors Hospital of Augusta in Augusta, GA.

Meganjoy Whelan is affiliated with Doctors Hospital of Augusta in Augusta, GA.

Joan Wilson, MSN, MHA, RN, is affiliated with Joseph M. Still Research Foundation, Inc., in Augusta, GA.

1. Goodin HJ. The nursing shortage in the United States of America: an integrative review of the literature. J Adv Nursing. 2003; 43(4):335–350.
2. Murff M, DeFer T. Improving controllable nursing retention. Nurse Leader. 2010; 8(3):53-57.
3. HCA Leadership Institute. Participant Guide Peer Interviewing—Team Training. Available at https://hcahealthcare.com/nurses/nursing-at-hca/education-and-professional-development.dot .
4. Piccinin CJ, Hudlun N, Branam K, Moore JM. The effects of preceptor training on new graduate registered nurse transition experiences and organizational outcomes. J Contin Educ Nurs. 2018; 49(5):216–20.
5. Anthony MK, Standing TS, Glick J, et al. Leadership and nurse retention: the pivotal role of nurse managers. J Nurs Adm. 2005; 35(3):146–155.
6. Taunton RL, Boyle DK, Woods CQ, et al. Manager leadership and retention of hospital staff nurses. Western J Nurs Res. 1997; 19(2):205–226.
7. Kleinman CS. Leadership: a key strategy in staff nurse retention. J Contin Educ Nurs. 2004; 35(3):128–132.
8. Wallis A, Kennedy KI. Leadership training to improve nurse retention. J Nurs Manag. 2013; 21(4):624–632.
9. Nelson A, Frankenberger WD. Using focus groups to improve nursing satisfaction. Nurs Manag. 2020; 51(3):42–48.
10. Force MV. The relationship between effective nurse managers and nursing retention. J Nurs Adm. 2005; 35(7/8):336–341.
11. Twigg D, McCullough K. Nurse retention: a review of strategies to create and enhance positive practice environments in clinical settings. Int J Nurs Stud. 2014; 51(1):85–92.
12. Erenstein CF, McCaffrey R. How healthcare work environments influence nurse retention. Holistic Nursing Practice. 2007; 21(6):303–307.
13. Grant CL, Lusk JL. A multidisciplinary approach to therapeutic risk management of the suicidal patient. J Multidiscip Healthc. 2015; 8:291–298.
14. Al-Mousawi AM, Mecott-Rivera GA, Jeschke MG, Herndon DN. Burn teams and burn centers: the importance of a comprehensive team approach to burn care. Clin Plast Surg. 2009; 36(4):547–554.
15. Cook J, Beresford F, Fainardi V, et al. Managing the pediatric patient with refractory asthma: a multidisciplinary approach. J Asthma Allergy. 2017; 10:123–130.
16. Prestifilippo, K, Webb, E. Employee survey records. Advanced Burn and Wound Clinic, Doctors Hospital Augusta, May, 2018, November 2019.
17. Martin L, Kelly MJ, Roosa K, et al. Multidisciplinary approach to improving pain management. Crit Care Nurs Q. 2012; 35(3):268–271.
18. Rask R, Smith L. Principles of peer interviewing. J Stud Res. Available at http://www2.uwstout.edu/content/rs/2006/17rasksmith.pdf . Published 2006.