Turnover in phlebotomy: looking deeper than pay

Amy Carpenter Aquino

April 2018—Laboratory managers struggling to reduce turnover among phlebotomists should look beyond the pay and examine their hiring and management practices and the dysfunction that could be creating walls between analytical and preanalytical staff.

“It’s an enormous problem,” Dennis J. Ernst, MT(ASCP), NCPT(NCCT), director of the Center for Phlebotomy Education, says of phlebotomist turnover. “There’s no silver bullet because there are so many things that lead phlebotomists to give up hope where they work and in the profession. It’s critical that managers are tuned in to the needs of this specialized workforce because they’re varied and many.”

Salary is the first consideration because it’s tangible, says Susan E. Phelan, PhD, MLS(ASCP)cm, recently retired department chair, health sciences, and phlebotomy program coordinator, Moraine Valley Community College, Palos Hills, Ill. She recalls outstanding students who worked for a while but who returned to their former jobs as waitresses where they could earn more. And “talent is easily lured away” in the competition among hospitals for preanalytic staff, if there is little other incentive to stay, says Beth Warning, MS, MLS(ASCP)cm, an instructor in the College of Allied Health Sci­ences, University of Cincinnati.

But salary is often not the main reason a phlebotomist leaves a position. “When people leave organizations, they don’t leave the organization. They leave managers, if they feel they’re underappreciated, somehow disenfranchised, or at worst treated poorly,” says Dr. Phelan, who spoke with Cap Today recently and was a panelist last fall, with Warning and others, at the Global Summit on Best Practices in Preanalytics, sponsored by Greiner Bio-One North America.

Ernst, who moderated the panel on phlebotomist retention, says a pay raise is only temporary satisfaction if the work environment is not supportive. “There’s always this wall between laboratory and nursing departments, but the wall that gets less attention is between those who draw the samples and those who test them.” And the friction between them “leads to disillusionment,” he says.

Lack of ownership in laboratory decisions is a common complaint of phlebotomists, who often feel like “the neglected stepchildren of the laboratory,” Ernst says. “They don’t feel they’re part of the laboratory because they’re not pulled into some of the processes and decisions that are important for them to have a voice in,” he says. This causes preanalytical staff to feel they are “subjected to decisions instead of part of them.” Managers who involve preanalytical staff in decision-making reinforce that they are a critical component of the laboratory and patient care.

Also common is a lack of respect. “In almost every lab I’ve worked in, the phlebotomists were looked down upon by those who tested the samples,” Ernst says. While there are exceptions, “generally speaking, there’s this pecking order that needs to be obliterated and replaced by a team concept.”

“I think it’s an undervalued skill,” Dr. Phelan says of venipuncture performed by phlebotomists. “There are hierarchies in every group, and phlebotomy is always considered low, low on the scale.” But if managers show respect and require their teams to show mutual respect, Ernst says, phlebotomy longevity is more likely.

Dr. Phelan says phlebotomists are often unfairly blamed for errors that are assigned to the laboratory. Most of those errors occur preanalytically, though many don’t fall under the laboratory’s domain. “This is about shedding light on where the problem is. If you look at ERs, for example—and even more specifically, blood culture contamination rates in ERs—non-laboratory personnel have a much higher contamination rate than persons who are trained by the laboratory.”

“There’s data to suggest that more training is needed, led by the laboratory for non-laboratory personnel,” she adds.

An unprofessional work environment, marked by inappropriate language, off-color humor, or bullying by managers or coworkers, is another problem. “This is the toughest one for a manager to provide because when it comes to decency in the workplace, unless it is propped up, it will fall to its lowest level,” Ernst says. He advises managers to have high expectations for professionalism.

The effects of bullying within some areas of health care are well documented. For example, a Vanderbilt University study found that 60 percent of new nurses left their first position within six months because of lateral, or nurse-on-nurse, bullying. While this type of “eating their young” bullying among phlebotomists has received less attention, phlebotomy has a similar problem, Ernst says.

“When a longtime phlebotomist thinks they’re the queen bee, and new people are hired who are perhaps of a higher caliber, the queen bee will chase them right out by making their life difficult,” he says. “Managers have to know what bullying looks like, and they’ve got to be able to react decisively. Any facility that has a revolving door on the preanalytical staff—where people are coming in and six months later they’re going out—is a house on fire. They need to roll up their sleeves and answer this question: Do I have a bully in the house?”

The worst approach is to ignore staff complaints about and other indicators of a potential bullying problem, Ernst says. Bullies are adept at concealing their actions, and a manager’s failure to recognize the problem and take action can result in a consistent loss of fresh phlebotomy talent.

Some turnover stems from phlebotomy students having viewed phlebotomy training as a shorter path to a health care career, Warning says, only to find later they are unprepared for the 4 AM start times required in hospital settings. Other students see phlebotomy as a stepping stone to a higher-level position in the laboratory or nursing. “You hate to see your talent leave, but you also know you helped develop them to who they are as they move on to other positions,” she says.

Retention strategies vary, and some require organizational and financial resources to implement.

Dr. Phelan says research on the costs and benefits to a health care institution of providing clinical education is thin, but points to an advantage when a hospital offers clinical training to students and subsequently hires them. The new employees tend to stay, and “the retention appears to be for a longer duration than, for example, hiring somebody off the street.” One reason, she says, may be that the clinical training period serves as a prolonged job interview.

Peggy Machon, PhD, RN, who also was on the panel last fall and who retired recently as dean of the career programs department at Moraine Valley Community College, says having preceptors train new preanalytical staff in their first days in the lab is key to conveying the organization’s mission, vision, and culture. “Developing a sense of belonging is so important,” she says.

That goal is not always attainable, though, because of time constraints. Attendees at the panel discussion said safety, accuracy, and efficiency were bigger concerns for newly hired phlebotomists, who “have to hit the ground running” because laboratories are short-staffed, Dr. Machon says. “There was not one person in the audience [at the summit] who felt they were sufficiently staffed.”

If labs can’t pay phlebotomists what they’re worth, smaller investments, such as a monthly birthday club, and more substantial investments, such as continuing education, can help to make them feel appreciated, Dr. Phelan says. Acknowledging good work with praise, or with a promotion to a trainer or mentor position, shows phlebotomists they are valued.

Encouraging certification and paying for the certification exam are also helpful, Ernst says. “When a person can tag credentials on the end of their name, that gives them a sense of pride in their profession and a sense of ownership of a procedure. That’s critical for the individual to be retained in the workplace.” Most certification exams cost about $150, he says, much less than the cost of losing an employee and retraining a replacement.

Given all that is required for successful laboratory management, Ernst recommends that managers focus on building and reinforcing their own leadership skills by attending training programs on managing health care personnel. “It’s not easy being a manager,” he says, “especially when you’ve risen up into your position as a manager from a place on the bench.” Many laboratory managers were never professionally trained to supervise staff. “You’re a manager because you were good at being a technologist. That doesn’t make you a good manager,” he says. “Unless you actively go out and seek management skills, you’re probably not good at solving personnel problems or recognizing them.”

Whatever the skill level, managing a new employee who may not be a good fit can be tricky. “It really was a concern in the audience, because they are so short-staffed, that it’s very hard to let someone go when you have a warm body,” Dr. Machon says.

Managers have better odds of avoiding the fit problem if they use a hiring process that incorporates peer interviews and establish a mentoring program for new phlebotomists, one that “shows them how things get done and how to behave or act,” Ernst says.

Some managers mistakenly hire preanalytical staff based on technical skill instead of demeanor, professionalism, and personality and then polishing the person’s skills on the job. “There are certain values you can’t teach,” Ernst says. “So you hire values and you teach the technical. Almost everybody can be taught how to draw blood properly.”
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Amy Carpenter Aquino is CAP TODAY senior editor.