Los Rayos del Sol Medical Center is a hospital and surgery center located in Florida. Its main facility has 500 beds and several outpatient centers, it employees 2,600 people, and has recently partnered with the Mayo Clinic. Despite this seeming success, Los Rayos is experiencing high turnover amidst its nursing staff. The nurse average turnover rate is 14% for hospitals,83 while Los Rayos has a turnover rate of 21%. New graduate nurses turn over at a rate of 27% within their first year, with an additional 37% of those new nurses wanting to leave, according to a survey conducted nationwide.84 At Los Rayos, new-nurse turnover is 40%. The hospital spends an average of 13 weeks85 to fill a vacant position and thousands of dollars per hire.86 Turnover often leaves units understaffed, which creates poor patient experiences, nurse burnout, and lower quality of care. It also cuts into the firm's bottom line.

Why are the nurses leaving? Los Rayos strives to provide the highest quality in patient care, but it also has to manage costs and comply with the new government regulations from the Affordable Care Act. Thus, over the last 10 years, Los Rayos has made a number of changes.

• Ten years ago, Los Rayos changed the staffing model. All units had two licensed nurses and a housekeeper. Housekeepers were minimum-wage staff that helped the nurses do things like wash linens and stock the nurses' station with basics. These tasks can take a lot of time away from the normal nurses' job duties of doing rounds, required charting, administering doctors' orders, and helping patients. Los Rayos promoted the housekeepers to health techs, which were supposed to do more patient care tasks, but most were not equipped with the skills needed to do these advanced tasks and were not given training by the hospital. At the same time, Los Rayos reduced the number of nurses per unit by one. This raised staffing ratios from 12 patients to one nurse to 24 patients to one nurse.
• Eight years ago, Los Rayos cut the annual employee picnic and Christmas party in order to save money.
• Five years ago, Los Rayos expanded nurses' jobs to engage in activities like cost-cutting and quality control. It required nurses to provide three to five cost-saving ideas per year or they would be negatively evaluated on their performance appraisals. The next year, the firm put a cap on each position's wage brackets, which resulted in nurses with greater than 12 years of service not receiving raises.
• Three years ago, Los Rayos removed the intake coordinator position from all units except the ER and laboratory. This means that unless a patient is admitted to the hospital in the ER or immediately after laboratory testing, the nurse(s) on the unit has to complete the admission paperwork when the patient is brought to the unit.
• Two years ago, Los Rayos began using tablets for patients' charts and tracking and dispensing medicine. To prevent drug theft, medicine carts were equipped with a new security system that requires nurses to scan a patient's hospital bracelet with the tablet, select the medication, and confirm the order before the tablet will send the information to the cart and unlock the needed medicine. The process often has technical problems or delays and causes frustration to both nurse and patient.
• A year ago, Los Rayos began requiring all its nurses to take turns developing, planning, and presenting continuing education courses to reduce training costs. Nurses are required to complete 60 hours of continuing education annually for license renewal. The nurses did not receive any additional compensation for the training they developed, nor were they given any nonmonetary rewards.
• Six months ago, Los Rayos changed from 8- to 12-hour shifts to reduce costs and to allow patients to be closer to their caretakers. However, patients from the maternity and geriatrics wards have complained about only seeing nurses at the start and end of shift and have negatively rated their hospital experience on surveys. Some employees like 12-hour shifts; however, most employees agree these shifts are exhausting, and the nurses often state they don't have the time and energy to "go the extra mile" for colleagues and patients.

How the changes Los Rayos made affected nurses' attitudes? What problems to the business may poor nurse attitudes cause in addition to turnover?