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Alternative Care Models in Midst of a Nursing Shortage

A combination of patient surges in 2020-2022 and nursing shortages have forced healthcare organizations to pursue new strategies for care delivery, or alternative care models. Pre-pandemic care models are stretching thin during a nurse shortage, so many U.S. health systems are rethinking their labor resources.

Health systems are deploying alternative care models to address a nursing shortage, and its all-hands-on-deck! Team-based care is becoming a new reality. Team nursing allows for clinicians with varying skill levels to collaborate in providing patient-centered nursing care.

A team-based care approach brings together RNs, unlicensed assistive personnel, and LPNs with other disciplines (including physical therapists and rehab therapists.) By distributing appropriate duties to LPNs, UAPs, and less-experienced RNs under the direction of an experienced RN, a team-based care model has shown it can enable care settings to do more with less. Each unit will have to determine how many patients the experienced nurse/team leader can handle based on the acuity and number of patients.

A Case Study – Advent Health Celebration

Advent Health recently completed a study that looked at integrating LPNs to help nurses with care delivery needs (Click Here – The Impact of an Innovative LPN-RN Care Delivery Model). LPNs were hired into the acute care setting to work on a team-based nursing care model alongside RNs. Previous research provided evidence that LPNs’ unique skills can address escalated workloads, as well as enhance clinical outcomes and the quality of care provided.  Advent Health’s research is evidence that implementing a new care delivery model can help address staff resource issues and provide adequate patient care.

Advent Health’s study also revealed that the model of care enhances the nurses’ work environment in the areas of autonomy, control over practice, and teamwork. Several campuses within Advent Health have now implemented LPN-RN programs. It will now start to develop standardized processes to train and orient more LPNs to enhance this model. There is some evidence that LPN models are not as effective in fast-paced/high turnover environments as those with longer patient stays, but the health system will continue to monitor this.

Besides altering care delivery to include unlicensed staff and moving to team-based care delivery, here  are two other tactics to help fill in care gaps and minimize effects of a nurse shortage:

Cross-Training + Float Pools of Nurses/Staff

Hospitals are cross-training nurses in non-critical areas to fill labor needs on the critical care areas. Float pools can help to manage this issue. Utilizing and cross-training float pools can help redeploy labor resources easier and fast. This more agile labor model involves cross-training a pool to work across adjacent specialty areas and as a backup, having the full-time staff cross-trained to work across adjacent specialties in an emergency situation. This interdisciplinary team-based approach allows for rapid deployment of staff to areas of high need. Besides just helping with labor needs, when a hospital has more nurses trained to work in adjacent areas, it’s more feasible for staff to take time off and recharge.

If hospitals are only relying on staffing agencies to fill all vacancies it can be unsustainable and costly. Agency staffing should be used to fill in gaps, not the pillar for staffing an organization. For extra hands-on-deck, future care settings will likely collaborate with nursing schools and training programs (or even state and local governments) for unlicensed providers to increase the talent pool where the needs become urgent.

Strategic Investments in Staffing Data and Tech

Health systems are adding tech tools to handle labor-some tasks more efficiently. This includes robotics, telehealth, mobile-first technology, plus using professionals with specialized skills to minimize the supply issue.

Scheduling technologies allow for shift and vacation bidding to help balance personal and work life. Some acute care hospitals rely on manual scheduling models when handling day-to-day staffing needs, so this technology could be used more frequently.

Nurse leaders are saying that data is essential to adequate staff planning. It can help predict how many nurses are needed per shift/unit, minimize nurse frustration regarding assignments, identify staff issues such as burnout and weekend duty, and help justify budget requests.

For hospitals and health systems interested in nursing retention and healthcare career pathways, Catalyst Learning offers a variety of workforce development tools for your frontline team.  Contact us at info@catalystlearning.com or 502-584-7337. 

Sources:

“The Impact of an Innovative LPN-RN Care Delivery Model,” Advent Health Celebration, Marie L. Desir MSN, RN, CCRN-K, Deborah Laughon MSN-Ed, DBA, CCRN, CENP, AONL National Conference 2022

“Nursing’s Wakeup Call: Innovative Approaches to Talent, Technology, and Care Models,” Health Leaders Media, Anne Dabrow Woods DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN, April 22, 2022

“The nursing shortage demands boldness and creativity. Now.,” Wolters Kluwer, April 1 2022

“Building Capacity in a Pandemic,: An Alternative Staffing Model,” AONL, Laura Jansen, MSN, RN, CNML, Kelly Poskus, MS, RN, CNRN, Jeannette Bronsord, DNP, RN, NEA-BC,  Sept. 2020

“Bringing Back the Team Approach: It’s Time for Alternative Staffing and Onboarding Models,” Lippincott NursingCenter, Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN, March 26 2020

“Cross-Training for Workforce Resiliency,” Minority Nurse, Michele Wojciechowski, September 14 2021

“Nursing’s Wake-up Call: Change is Now Non-Negotiatble,” Nursing Workforce Survey, UKG/Wolters Kluwer, Nursing Workforce Survey – Nursing’s Wake-up Call: Change is Now Non-negotiable (ukg.com)

Creating a Culture of Connection

This health system newsletter is a summary of Catalyst Learning’s webinar entitled “Creating a Culture of Connection: Proven Strategies for Success.”  To watch the webinar, click here.

The 2022 workplace is being reshaped with a lens toward how the employer-employee relationship is changing.  Workers are questioning their career choices, and employers are asking themselves what is needed to improve retention and how they can better serve the needs of associates.  HR leaders in healthcare are looking at how their people experience community, communication, work appreciation and connection to company values.

One way to more strongly meet employee needs is to create a culture of connection. The BlueBoard organization recently released it’s The State of Workplace Connection Report 2022 and found that employee connection is key to driving critical outcomes in employee happiness, retention, and engagement.

The State of Workplace Connection Report 2022 recognized these as the top ways organizations are working to improve employee connection:

  • Hybrid in-person and online events
  • Formal employee appreciation and recognition
  • Adding tech for better remote communication and collaboration
  • Manager and leadership training
  • Expanding employee learning and development opportunities

How can organizations start creating connections on Day 1? Culture-based Onboarding.

Jacque Burandt, President of Award-Winning Results and former Chief Learning Officer at University Health in San Antonio outlined how a poor onboarding experience can be very costly to employers. According to OC Tanner data, 69% of employees with great onboarding stay 3+ years.  The Gallup organization connects onboarding to safety, citing a study of 200 hospitals in which engaged nurses are the #1 correlation to decreased mortality. 

To connect onboarding to culture, Burandt recommends including the strategic plan and talking about vision and values in active, engaging ways that provide maximum opportunity for interaction.  Involving senior leadership, either in person or virtually is vital.  So are providing an understanding of the patient experience model and recent survey results.  Onboarding also provides opportunities to help new employees connect from day one and establish individual relationships across the enterprise.

To learn more about health system onboarding and creating a great first impression for the Culture of Connection, read more of Burandt’s wisdom in the ATD Talent Development and Training in Healthcare Handbook, Chapter 11, Onboarding.

Increasing connections with nursing and non-clinical team members at East Alabama Health (EAH)

Susan Johnston, VP HR at East Alabama Health, shared her perspective that the Great Resignation goes beyond the employee/employer connection with a poignant story about two experienced nurses who had recently resigned because their “work family” had left her organization.  

Johnston shared 3 strategies that are a focus for retaining employees:

  • Boosting flexibility with multiple staffing models
  • Increasing connections with nursing workforce to understand issues. 
  • Recruiting a strong entry level workforce and upskilling them to fill future needs

To focus on nursing staffing and workload, EAH does daily reviews at the senior level of unit staffing to ensure ratios are met. It created a Nursing Supervisor position during the pandemic to give more support to unit managers and is exploring alternative staffing models to assist with more “hands on deck”.  New roles for LPNs, admission/discharge nurses, interns and medication assistants are either being explored or have been implemented to support the primary nurse role.

The Nursing Advisory Council plays a key role in building connection between leadership and staff nurses to communicate, inform, and build trust; emphasizing transparency and consistency.  Staff serve a two-year term and are compensated for participation.  And charge nurse management training continues to provide an important benefit to nursing staff, ensuring there are trained leaders on the floor.

Like many healthcare systems, EAH is a vital employment anchor in its geographic communities.  Embedded in its culture is a commitment to recruiting strong entry-level workers from the community and upskilling them.  EAH creates career paths through a salary structure that encourages staff to achieve certifications and new skills. School at Work (SAW)® helps with career development and 53% of SAW graduates have been promoted within the organization.  EAH created pipelines for entry-level staff to become nurses, respiratory therapists, and other allied health professions.  EAH’s scholarship program for SAW graduates pays for all community college pre-requisite courses.

To promote a culture of connection, and an environment where employees feel supported and heard, EAH keeps a pulse on changing employee needs and expectations within HR and across senior leadership. It keeps the CFO informed of the cost of turnover, because investment in staff is very small when compared to turnover cost and low engagement. Senior staff helps employees to see internal opportunities which are available to career build and creates two-way communication so staff know they are supported, recognized and heard.

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Next Steps

To explore how front-line employee learning, from support positions to charge nurses, can increase your culture of connection, contact Catalyst Learning at info@catalystlearning.com 

To learn more about creating a culture of connection, click here for the webinar slides and recording.

To support professionals in your healthcare HR and Learning organization with their own professional development, consider the ATD Talent Development and Training in Healthcare Handbook

East Alabama Health (EAH) Creates a Culture of Connections, Builds Careers from the Frontline-Up

East Alabama Health (EAH) in Opelika, AL is a 340-bed hospital with regional clinics, that serves an 11-county area. With ~3,500 employees, EAH is the second largest employer in its metro-area, second only to Auburn University. The primary mission at EAH is to deliver high-quality, compassionate health care to every patient, every time.

EAH has long been an investor in its employees, including support for those at the entry-level.  In 2005, Vice President of Human Resources Susan Johnston became interested in workforce development as a strategy to be sure EAH had a steady supply of workers who were interested in healthcare.  “I heard a presentation in DC that a hospital made about its partnership with Catalyst Learning and knew right away that I would bring that back,” said Johnston.

Fast forward 16 years and EAH has seen hundreds of employees participate in its workforce programs, including those who have graduated from Catalyst Learning’s School at Work® (SAW) experience.  SAW is a comprehensive education and career planning system for a health system’s lowest paid employees that helps associates prepare to move from low-wage jobs to those family-sustaining wages.  

In a recent multi-year internal study, EAH saw that 53% of SAW graduates received a promotion and 55% utilized EAH’s scholarship programs to further their education.  The individual successes are many and impressive.  A few examples include:  a transporter now a business office manager; a housekeeper who went to EMT school and is now a paramedic; a young mom who was an MCT and is now a nurse; another who is now on the nursing advisory council.

Diversity, Equity and Inclusion – Walking the Talk in Workforce Development

According to a 2020 report by the Center for Economic and Policy Research, workers of color are particularly overrepresented in front-line healthcare jobs.  The same is true at EAH, causing Johnston to be focused on how to advance diverse employees within the organization.  “It’s a huge part of my initiative to flood our organization with more diverse populations for our professional positions.  We must be champions of promoting from within and advocates for investing in people who live in our community.” Johnston believes the “grow from within” approach is a key element of solving the staffing nightmare that much of healthcare finds itself in today.

East Alabama Health, School at Work Graduates

We asked Susan if EAH’s investment in the entry-level employees was connected to a DE&I initiative.   And the immediate response was, “Absolutely. When I look at how our organization stacks up to our community, a lot of our diverse population is in our entry-level workforce.  We ask ourselves, why don’t we have more nurse managers who are black or brown? Well, we don’t have a lot of nurses coming out of nursing schools in our area who are black or brown. We have to get people in to be nurses so that they can become nurse managers. This is key to getting your workforce to become more diverse.”

Building A Culture of Connection – A Hands-On Approach

Johnston stays very close to programs like School at Work and Cornerstone, an employee-giving organization, by knowing and mentoring students and encouraging other EAH leaders to do the same.  She believes it is important for executives to understand first-hand the issues that EAH employees are facing, with those in lower-paid jobs sometimes living paycheck to paycheck or facing decisions about whether to feed families or put gas in their car.  “I want them to get to know these employees.  They’re fantastic, highly motivated, very capable people who we need to provide opportunities for.”

Lisa Ruffin, EAH’s Manager of Workforce Development describes the importance of other connections that the organization provides.  “HR is a great partner with the class.  They come in and help with interviewing, resume writing, and more.”  She also believes that the bond employee classmates form with each other is  a key to success.  “I like to pair the students who are very smart with those who may be struggling; the camaraderie  helps them excel.”  Ruffin is proud of the major impact she’s seen with a majority of participants moving up in the organization and many taking advantage of 2 free classes at Southern Union State Community College offered by EAH to help them get started. 

And the connections have just kept building!  New this year is a stipend scholarship for those who are highly capable and want to become nurses.  Says Johnston, “part of School at Work is the support and we’re trying to continue that.  They’re all at the community college together.  We’re staying with them.”

April Stapler, School at Work graduate 2013.  From General Cleaner/Housekeeping to RN

“My entire family is nurses. My mom, grandmother, aunt. Growing up, I didn’t want to be a nurse. I had kids young and started working as a housekeeper at EAH. Then nursing started to sound not so bad. I wanted to test the water to see if being around patients was something I was interested in before putting the time and money in. When being a housekeeper, you see how nurses, CNA’s, and tech’s come together as a cohesive group. I loved it. I loved getting to know residents, the people I worked with. I loved being involved in making a patient smile; being there when they weren’t having a good day. Nursing became my prime focus because the desire to care for someone, the desire to make a difference on their worst day became a passion for me. I graduated from nursing school in 2018.

“The entirety of the SAW program gave me the confidence to talk to doctors and other nurses. I feel like it gave me a voice, it put my name out there. From a housekeeper to a tech to a nurse.”

Jayme Cook, School at Work graduate 2020, Patient Resource Associate

“The confidence that I gained through SAW in myself and my abilities as a healthcare worker is what impacted me the most. My goal every day is to go home knowing that I helped somebody. Being able to build my own confidence as a person and healthcare worker and a leader – my biggest goal is to be a mentor. I want my coworkers to think if there is a problem, they can go to Jayme to figure it out. If she can’t figure it out, then she’ll help us find someone who can.”

Charge Nurses Are Also “Chief Retention Officers”

Organizational loyalty is cemented through relationships with supervisors and managers, but don’t overlook the importance of the Charge RN role to nurse loyalty and retention.  Turnover studies show that more often than leaving an employer, staff leave their first-level supervisor.

Charge Nurses play a role in onboarding, coaching, patient experience and safety, and nurse retention.  Develop your Charge RNs to be unit leaders, by teaching critical thinking, delegation, effective communication, conflict management, leading through change, and other qualities for successful leadership.

How can a Charge Nurse help your organization with nurse retention?

Being a Leader Who Fills In Gaps

It’s obvious that nurses on the team are busy, overworked, and possibly stressed. Your team may be understaffed at times, or during this Covid/Delta-era, understaffed most of the time. This means nurses on the team or unit could be behind on charting, procedures, assessments, or administering medicines. This may slow down throughput, and it could impact patient satisfaction or even outcomes.

A Charge RN can be the first line of defense to keep the unit productive and nurses happy. She may need to fill in in placing IVs, triage patients, get EKGs, or order medications. The Charge is a leader who fills in gaps of care or administration, quarterbacking and motivating the team, whether it’s normal times or Covid-times. This type of leader keeps team morale on an even-keel which helps with nurse retention. On the flip side, an unprepared Charge Nurse can have the opposite effect.

Helping Nurses Manage Stress and Keep Calm

Of course you want all nurses to be calm in emergency situations, but in the Charge role this is especially important. Charge Nurses put out fires during the shift and oversee that other nurses handle stressful situations properly. A Charge Nurse who knows her stuff and understands key policies can take the air out of a stressful situation.

The Charge Nurse can also help alleviate nurse stress by keeping the shift organized. Charge RNs should make prioritized lists and help chart in real-time to avoid backlog which can also cause stress.

Being a Communication Line Between Management and Nurses; Identifying Problems Early and Intervene

Charge Nurses should foster nurse communication and gather input for the organization. They may have the best intel on how the team is perceiving and reacting to what is going on.  Help your Charge RNs understand how to use “chain of command” when escalation is needed (and not needed).

Continuous, open communication, however, makes nurses and all of us feel valued.  Charge RNs can help identify workplace incivility early. These incidents can lead to low team morale, low productivity, and increase absenteeism. Conflict is unavoidable and problematic, so nurses with strong conflict resolution skills are better able to deal with challenges quickly and reduce potential errors stemming from it. A Charge RN can also identify staff who are struggling and help with early interventions.

Be a Model of Positivity and Professionalism

Encourage Charge Nurses to lead by example, and always look for ways to help the team succeed. Encourage your team to practice positivity and professionalism by showing initiative and by thriving under direction. Let Charge RNs know that serving as a good example and demonstrating a strong work ethic, flexibility, and positive attitude will help pave the way to future leadership positions. It isn’t just about “soft skills” of leadership either, because these are skills which will impact issues like organizational financial goals, patient outcomes, and patient experience.

You may not be thinking about how Charge RNs can be a key part of your nurse retention efforts. Nurse Managers can’t do it all alone.  Reward Charge Nurses with professional development and watch the change in team dynamics! 

To assist health systems who would like to sample the power of charge nurse development, or are strapped for instructors in these staffing-challenged times, Catalyst Learning is teaching public NCharge® “Nurses Learning to Lead” classes in Oct-Dec. Learn more about our upcoming virtual, instructor-led course. Courses carry 3.5 ANCC contact hours.


“Be the Boss No One Wants to Leave,” Webinar by Rose O. Sherman, 9/28/21, sponsored by Catalyst Learning Company

“Letters: Embracing retention at all levels,” Lippincott Nursing Center/Nursing Management magazine, Kathy G. Newton RN, Florence Stewart RN/BSN, Sabra Henry RN/BSN

“Strategies for Nurse Retention,” Elite Learning, Lorraine Mercado

“Recognizing and Overcoming Toxic Nurse Leadership,” RN Journal, George A. Zangaro PhD/RN, Kelly Yager MS/RN, Joseph Proulx, EdD/RN  

“Improving the Charge Nurse ‘s Leadership Role: A Collaborative Learning Forum,” Walden Education, Felicia Katherine Pryby, 2016

Leadership Research Findings: Key Factors for Entry and Mid-Level Employee Development

Every year Catalyst Learning asks its customers, Talent Management and Learning  leaders at health systems across the US, to help us understand front-line employee development priorities.  This focus of this year’s survey was non-clinical employees at the  entry and mid-levels. Not surprisingly, during the Covid/Delta staffing vortex, there are big concerns about staffing and skill shortages in healthcare. 

Highlights of the survey are below.  To learn more about how Catalyst Learning is incorporating this information into development of the Next Generation of School at Work® and ECHO® experiences, contact us at info@catalystlearning.com.

Why do healthcare DLO leaders invest in entry or mid-skilled non-clinical associates?

Results for the request to select single, most important factor in determining “why you invest” were almost a dead heat between these two reasons:

  • Direct ROI, whether retention, promotion, or both
  • DE&I connections related to employees in entry-level roles.

An altruistic lens towards associate skill investment was not supported as a reason to invest in entry-level and mid-level employees. Concerns related to automation were also low on the scale. 

When quizzed about the types of roles of most interest, developing employees for clinical roles is the overwhelming choice; with Support and IT-related role development of relatively little interest.  Positions both in-demand and seen as attainable with certificate or associate-degree level of education included: Medical/Clinical Lab Technicians, Medical Assistants, CNAs, and Surgical Techs.  When mentioned, support roles most needed were billers, coders, and call center reps.

Given the immediate need for quality workers during the pandemic-induced labor shortage, a focus on RoI and skills is probably not surprising. Filling a talent pipeline for both high need roles and a broader array of jobs is mission critical for our customers right now.

Career Coaching at your health system?

If health systems are willing to get more committed to “growing from within” in this era of high turnover, we next wanted to learn if they have the internal capacity to make this happen.  Overall, the feedback from our panel of L&D Directors and VPs was that they do not have an employee whose full-time job it is to coach low skilled workers for new job roles. Coaching is more likely to be baked into other role descriptions and done informally.  One organization provides programming via the Career Center but doesn’t work 1×1 with employees.  Many of the leaders we received feedback from are School at Work® customers who have internal program facilitators who do 1×1 job coaching as a portion of their role.

This may change for some systems in the future though. When asked about the future state of career coaching to help lower skilled employees to assume more responsibility, 60% who do not currently have an FTE job coach remarked that they were likely to add one in the future. One respondent said that her system may even add an actual department dedicated to career pathway management. Some survey participants mentioned that a role/program like this would need to show ROI quickly to be considered, but given the need to fill in-demand roles, they are considering it.

Digital Literacy is now an essential skill for entry and mid-level non-clinical associates

It is not a secret that healthcare workplaces are more reliant on technology and that work at every rung of the employment ladder is becoming more digitized. Entry-level non-clinical roles now require the ability to interpret, create, and strategically use digital information. Environmental staff are using apps for communication and task management. Nutrition departments are receiving meal orders via iPads, and production supervisors look at predictive analytics to know how much food to order.

Regarding the level of importance of certain types of digital literacy that are needed by entry and mid-level non-clinical associates, here is how the responses stacked up when asked what was “very important”:

  • 92% – having skills to use computers and other technology tools for hospital-specific program
  • 77%  – having the ability to use digital information/communication technologies to find, evaluate, create, and communicate information
  • 54% having technology skills to use computers and other tech tools at work for widely used 3rd party programs like Word, Outlook, or Excel.

Given this focus on digital literacy, more DLO leaders at U.S. health systems are considering virtual instructor-led L&D learning options than in years past. While the pandemic has forced the growth of virtual delivery, the instructor-led in-person cohort is still the preferred delivery method for entry/mid-level skill development. Not surprisingly, many respondents cited that a hybrid learning model of multiple delivery modalities is preferred.

How Can I Be The Boss No Nurse Wants To Leave

This article is a summary of a digital workshop given by Rose O. Sherman and Catalyst Learning Company on 9/1/2021. Ms. Sherman’s presentation was titled “Become the Boss No One Wants to Leave: Nurse Recruitment in Turbulent Times.” Catalyst Learning sponsored the event in recognition of the heroic role that nurses played in the U.S. in 2020 and 2021.

Across the U.S., nurse leadership is struggling with unprecedented staffing shortages and high turnover. COVID-19 has been a ‘Quake Experience,’ a massive life change with aftershocks that will likely last for years. Nurses have experienced an impact both personally and professionally, leading to stress, burnout, exhaustion, hopelessness, and some disengagement. Nurses and other health staff may be reconsidering their professional lives, asking questions like “am I really supposed to go back to work like nothing happened?” “What is my economic worth, and am I respected?”  “Is acute care the right setting for me? Have I found the right work-life balance?”

In the midst of this nursing workforce landscape, nurses are leaving the hospitals and systems they work for. While burnout, stress, inadequate staffing and better pay may get more attention and headlines, a major reason that nurses leave organizations is lack of good leadership. A lack of leadership doesn’t just mean the nursing VP. All levels of leadership, including the Charge Nurse, play a key role in retention. Nurses look for stability, trust, compassion and hope from their leaders. Younger nurses especially have different work demands than their more experienced peers, with needs evolving from paycheck to purpose, from wanting a boss to wanting a coach, and they look more for frequent feedback than annual reviews.

So given this new reality, how can I be the boss that no one wants to leave?

Focus on a Healthy Work Environment, plus Focus on Unit and Team Culture

Unit culture is an invisible architecture that new staff sense quickly. To have a healthy work environment, Nurse Managers and Charge Nurses set the tone. Make sure these frontline leaders encourage nurses to ask questions, make nurses feel appreciated, and listen to staff concerns. Nurse leaders who inspire staff generally have a strong bias toward taking action to correct situations, are vulnerable and compassionate toward staff, and manage conflict and diversity of ideas well.

Teach frontline nurse leaders to have zero tolerance for disrespect and abuse. A Charge Nurse who sees and ignores incivility or bullying has just normalized the behavior. Staff then either become part of the hostile workplace or leave entirely.

What is something nurse leaders can do quickly to help with culture issues? Consider bringing back an old ritual, or even start a new one. During COVID madness, many teams lost the rituals that connected nurses to the team and created a psychological safety net for the unit.

One last thought to help with work environment is to create a culture of recognition. Give symbolic gestures to show that leaders appreciate nurses. Begin shifts with “thank you for being here,” nominate your staff for awards, write thank you notes, and attend events where staff are being recognized. If your managers and Charge RNs see you doing this, they will likely follow your lead.

Do what you can do to encourage group cohesion and stronger work teams, remember that a toxic culture will destroy the best plans. Focus on work culture will help make leaders that staff do not want to leave.

Develop Charge Nurses to be Unit Cohesion Leaders

Organizational loyalty is cemented through relationships with supervisors, managers, Charge Nurses and team members. Many nurses don’t leave a health system, they leave their first-level supervisor. Develop your Charge RNs to be unit leaders, by teaching critical thinking, delegation, effective communication, conflict management, leading through change, and other qualities for successful leadership. Charge Nurses are the first-level supervisors who play a role in retention, onboarding, coaching, plus of course patient experience and safety.

Be Flexible to Meet the Needs of Your Staff – Be a Coach for Younger Nurses

Older nurses are retiring fast, and even Gen X makes up barely a quarter of the nursing workforce. Gen Y and Gen Z make up 60% of the nursing workforce now. As a leader, don’t wait for these Millennials to grow up and become Baby Boom or Gen X nurses. It is not going to happen. Be flexible in your leadership style to meet needs of younger staff. Be as accommodating as possible with work schedules for example. Also be flexible in your leadership style by trying to think more like a coach than a boss. Younger nurses think more about purpose than prior generations, so show young staff how their role contributes to the mission of the organization.

Lifetime employment is not the goal of most nurse staff today. Staff are more likely to see their jobs as “tours of duty” on a professional career ladder. To show support for Millennial and Gen Z nurses, support nurses’ career goals and do not give any perception that you may hold associates back from moving to the next level. Ask your nurse staff questions to aid their career development with questions like: “what goals do you have,” “what types of professional roles have you considered,” “what obstacles are you encountering,”  and “what new skills do you want to achieve.” Consider using a Career Development GROW® Model Coaching Template with nurses to show you value their career trajectory.

Communication is Key, Especially During Turbulent Times

In complicated times, transparent communication and visibility is key. When leaders don’t communicate, staff will fill in gaps with misinformation. Nurse leaders should practice effective communication during practice and policy changes, consider diverse communication styles among different staff, and choose the right words and tone for communication. If leaders do not communicate effectively it can lead to gossip, mistrust, perceptions of staff favoritism, and staff can become defensive.

The correct communication tone and style can be difficult even during ‘normal’ times, but it is even more critical when staffing is short. When there are staffing issues, make sure leaders are transparent about the challenges the team is facing. Make sure leaders are transparent about recruiting tactics that have been tried, ask for staffing ideas from the team, and acknowledge that nurse leaders do not have all the answers. It may be a difficult message, but staff will appreciate honesty, and may even be able to help.

STAY Interviews and Strategic Off-Boarding

STAY Interviews are a way to help with avoidable turnover. Aim to do at least 2 each year per nurse, the first one within 90 days of hiring. After this interview, note the actions that you will take and the actions the nurse/staff member will take. After this interview, use a stoplight method to assess risk of turnover, with green being likely to stay 1+ years, yellow to likely stay 6-12 months, and red a high risk for immediate loss. Ask questions like “what do you look forward to each day,” “what are you learning or do you want to learn,” or “how can I make your job better or want to stay?” Even if you are likely to lose an employee in their current role, you may find other internal roles that may be better professional fits. STAY interviews can help with internal mobility which reduces recruitment costs, and keeps high-potential staff in the organization.

If and when nurses do leave, stay upbeat and positive. Thank them for their contributions, and remember that other staff will watch how you manage resignations. When valued staff resign, think about how to create loyal alumni who will recommend your organization, and leave the door open for boomerang employees.

Catalyst Learning produces the curriculum NCharge™: “Nurses Learning to Lead” for Charge Nurses, which is available for on-site or virtual instruction.

Nurse Managers and ANM’s: Key Players in Saving the Country. Pandemic Reflections

Nurse Managers and Assistant Nurse Managers in U.S. health systems have many things demanding their attention each day. And that is during “normal” times! The 2020-2021 pandemic created more challenges for managers in care delivery organizations. Nurse Managers were tasked with securing medical equipment, turning units into COVID-19 care areas, short staffing, and providing emotional support for nurses who were seeing traumatic events daily.

This was an event that no one could have prepared for, but now looking back, how can we put plan and prepare to put Nurse Managers in the best position to succeed?

Encourage Constructive Relationships with other Leaders

Make sure Nurse Directors have a relationship with your Nurse Managers that is based on mutual respect and accountability. Provide constructive performance feedback, which helps the manager grow and develop. Avoid micromanaging the manager though, as this could be interpreted as a lack of trust. In a constructive Director-Manager relationship, there is clear communication on expectations, a trust on judgment on operational decisions, and a mentor relationship being built.

Do your Nurse Manager have collegial physician relationships? Nurse Managers and physicians partner to achieve quality patient outcomes. Talk with your managers about this and see if they have a physician partner who looks out for them, and wants to help them to improve patient outcomes in the manager role.

Encourage Nurse Managers to be Transparent about Rocky Times

Nurses do not expect their managers to have all the answers to problems, but they do want the truth. If there is transparency about instability, and a manager acknowledges that the team is going through rocky times, it can be a building block for trust. It can also help solve the issues. When staff members have all the information on a topic, they may devise reasonable suggestions or alternatives to solve or improve a problem. Through transparency, nurse teams can mature more quickly.  A lack of transparency however can have long-term detrimental effects and lead to less trust, or even turnover.

Teach Nurse Managers to Think about Retention of their Team

At Catalyst Learning, one of the biggest issues we’re hearing from our customers and advisors is that short staffing of nurses is everywhere. We keep hearing that many nurses on teams are very young and inexperienced. Besides just natural cyclical employment, the pandemic pushed some early retirements of Boomer nurses, and a lot of experience has left the building. Unfortunately, there is little we can do about this.

For your Nurse Managers to be successful, they need an experienced team. So make sure they are thinking about retention, especially of younger nurses who may shuffle out quickly. Encourage managers to offer role clarity when nurses first start and communicate on critical issues. Teach managers to offer recognition to make their team feel valued, intervene when disengaged nurses become disruptive, and offer opportunities for growth for high-performing young nurses. If your Nurse Manager plans on how to keep nurses engaged in the role and in the job, it will pay off.

Promote Stress Management and Nurse Resiliency from the Top-Down

It’s obvious that fatigue sets in during stressful times, and nurse burnout happens even during “normal” times. Nurse resiliency is vital to our public health community, but how can we prepare Nurse Managers to help staff, and deal with it themselves? Our systems can promote resiliency from the top-down by encouraging nurses to take emotional breaks, like music, hobbies, exercise, or personal spiritual events. You can encourage Nurse Managers to huddle with their teams and teach nurses to recognize what they can and cannot control, and that other nurse teams are scared too. And you can encourage nurses to pursue emotional support and connectedness to peers, have work teams find a buddy who they can reach out to when workload is intense, and promote Employee Assistance Programs that your health system has for associate support.

Collaborate to Create a Great, Thriving Environment

OK, a Nurse Manager’s role is hard, the word “Fun” may not make sense. But you can help create an environment that focuses on positive attributes of the role. For example, encourage your Nurse Manager to recognize excellence in nursing practice when she sees it in her unit. That will be beneficial to her and the team. Also check on your managers to gauge if they have a manageable workload, adequate resources, and accessible professional development to equip these leaders with necessary knowledge and tools.

Are you creating a culture of meaning and excellence for your managers? Do they feel like their role is just churning out work, or do they see how their work is evident throughout the entire health organization? When constructing your leaders’ priorities, show them how these priorities are aligned with the organization’s mission. Show your manager how her work supports the standards and expectations of excellence your organization has, and that her work helps maintain a reputation for excellence. Assure there is an alignment of goals and desired outcomes in performance evaluations to assist the manager in getting the work done through others.


“The Journal of Nursing Administration” October 2017 issue, entitled “Magnet Supplement The Role of the Nurse Manager: Pivotal to Nursing Excellence” – articles written by Jeffrey N. Doucette DNP/RN/CENP; , Nora Warshawsky, PhD/RN; Sharon Lake, PhD/RN; Arica Brandford, MSN/JD/RN; Mary Kay Rayens, PhD; Donna Sullivan Havents, PhD/RN/FAAN

“A Phenomenological Study of Nurse Managers’ and Assistant Nurse Managers’ Experiences during the COVID-19 Pandemic in the U.S.” Wiley Online Library, Jane H. White PhD, RN, PMHCNS-BC, FAAN, March 10 2021

“Behind every RN is a nurse manager: 4 tips for these leaders during the pandemic,” Beckers Healthcare, Mackenzie Bean, June 11 2020

“Exploring nursing managers’ perceptions of nursing workforce management during the outbreak of COVID-19: a content analysis study,” BMC Nursing, Sarieh Poortaghi, Mehraban Shahmari, Akram Ghobadi, January 29 2021

“Nursing leadership during COVID-19 Enhancing patient, family and workforce experience,” Patient Experience Journal (PXJ), Anne Aquilia (Yale New Haven Health), Karen Grimley (UCLA Health), Barbara Jacobs (Anne Arundel Medical Center), Maryellen Kosturko (Yale New Haven Health), Jerry Mansfield (Mount Carmel Health System, Trinity Health)

“6 Healthcare leaders share the most difficult aspect of their job,” Kelly Gooch, Beckers Hospital Review

“How to Build – and lead- resilient health care teams during COVID-19,” Katherine J. Igoe, Harvard School of Public Health, September 20, 2020

Another resource was Rose O. Sherman, who offered guidance letting us know of issues managers are facing. (July 2021)


Are you interested in related articles? Feel free to enjoy these as well:

6 Traits of Nurse Managers Who Are Transformational Leaders

It’s Time to Be Deliberate About Nursing Leadership Succession

Encouraging Nurse Resiliency Techniques During COVID-19

Why are Many Young Nurses Not Applying for Manager Roles?

9 Ways to Transform the Nurse Manager Role – Lets Make it Fun Again!

Hospital First-Level Supervisors: Did COVID-19 Expose Weakness?

First-level supervisors/managers in U.S. health systems have many things demanding their attention each day. And that is during “normal” times! The 2020–21 virus pandemic created more challenges for managers in care delivery organizations, including inadequate capacity, supply shortages, and adjusting workforce capacity to cope with changing needs and patient demand.

Even before the pandemic, many managers were not executing on the right behaviors to lead high performing teams. Did the pandemic show that your managers were not prepared for leading during intense times?

Managers have always mattered in hospitals/systems, but challenges have changed. Management now is about making employees the best at their role, while operating a cohesive team that can adapt during stressful times.

There are widespread reasons why managers are not prepared. One reason may be that management training and development is generally under invested in, especially for first-level supervisors. Also their associates are often just taught to “do their job” and are not invested in themselves. Many frontline health workers for example (nurses, CNAs, environmental, nutrition, administrative, tech positions, patient intake/registration) are not given behavioral skills education, leadership and development training, and don’t see how their own role contributes to the success and vision of the hospital/health system.

So…… how can we help our first-level managers?

Prepare them with emergency scenario information and to be adaptive

Don’t let your managers get caught flat-footed the next time a health crisis happens, be it a mass trauma event, natural disaster, terrorism, etc. Prepare communication chains from the top-down, then teach managers how to communicate and collaborate in a coordinated manner, giving managers autonomy to communicate how they feel is best for the team.

Improve hiring and promoting decisions, then focus on development

Systems need to evaluate and hire managers based on ability to serve the team. Do managers have the communication and people skills to get the most out of the team? Teach managers to hire or promote employees who seek to find operational answers to tough questions, not to answer all these questions themselves. Encourage managers to use skill and experience to develop the team, not to be the most “hands on” working member of it. This could lead to burnout, and will assure managers are not focusing on the right things.

Teach managers to focus on key behaviors of associates, and hold managers accountable

Managers tend to be evaluated by immediate and operational standards, such as were patients rooms cleaned quickly, is food service running effectively, or are patients and their families in the right spots for proper care or services. And at a higher level, hospital administrators look at HCAHPS and performance success indicators/patient scores to indicate how well a hospital is performing. But for evaluating a manager, these operational metrics can give an incomplete picture of management value. Other suggestions could be:

  • Making sure managers have a pulse on their intentional retention rates: Every manager should be able to identify who the performers are they want to keep, who are highest performing who may be lost to promotion, and which employees are not meeting expectations or could be more successful in other departments.
  • Keep managers focused on promotion rates: Managers are the first window into employees’ career pipelines, and/or career ladders for the organization. Managers should be preparing individuals to be promoted, and to take on more responsibilities and to learn more skills. If a manager never loses associates to promotions, they may not be developing their people well. See our related article, Geisinger (PA) Builds Career Pipelines for Individual Contributors.
  • Teach managers how to coach: While employees may understand tasks needed to perform in their daily job, they may struggle with more basic concepts such as time management or communication. A good manager helps frontline employees learn these and other soft skills because it makes the workers more effective in their jobs, and more satisfied with the work they do. See our related article, Frontline Employees: Coaching For Success.

Teach Managers to think about increased productivity and retention of their employees

Healthcare, just like retail, hospitality, and agriculture, struggle with frontline employee turnover and consistent productivity. It is difficult to simultaneously keep employee productivity high and turnover low. But there are a few tactics that can help our managers with productivity and retention:

  • Measure ROI from an organizational level
  • Teach managers to brainstorm moral improvement tactics for their team
  • Teach managers to give praise and better communication techniques
  • Encourage managers to help employees to build a personal development plan

See our related article, Increase Productivity and Retention of Entry-Level Employees.

Now we’re entering a new, brighter reality, with the world getting “back to normal” quickly after COVID-19. That is a really good thing! But when we look back at where we can improve on in the future, especially knowing that other traumatic events will occur, lets ask “were our hospitals managers prepared?” Did the pandemic push managers to the brink, or did it expose that they didn’t have the right skills to lead high performing teams in any environment? In all sectors of the U.S. economy, one thing we learned in the last 15 months is that front-line managers are critical to team success, and that many were not ready for the challenge. This is a risk going forward, so be proactive in how you prepare managers.

“Health Care Management During COVID-19: Insights from Complexity Science,” James W. Begun PhD, H. Joanna Jiang, PhD, NEJM (New England Journal of Medicine) Catalyst, October 9, 2020

“6 Healthcare leaders share the most difficult aspect of their job,” Kelly Gooch, Beckers Hospital Review

“COVID-19 didn’t challenge managers, it exposed them,” Brian Watkins, Chief Learning Officer, May 27, 2021

HR Trends & Workforce Planning at The VHA

The following is a summarized webinar hosted by Catalyst Learning and featuring with Ms. Shari Florio, Manager of the National Workforce Planning Team at the Veterans Health Administration (VHA).

Background – Veterans Health Administration National Workforce Planning

“We’re proud to be able to share our methodology and data with the private sector, as taxpayers, you should have visibility to this” – Shari Florio, Manager, VHA National Workforce Planning

The VHA’s annual workforce planning cycle accumulates data from the VHA’s 139 health care systems, to identify staffing shortage occupations, current and future workforce challenges, and other workforce planning needs. This data supports management within the organization with the correct analytics to better forecast employment needs.

The report helps with action planning, and best practices for recruiting and retention and provides information specific to the occupation groups that systems may be having issues in these areas. It also details why and where shortages are happening and helps with action planning to support recruitment of occupations that are most critical.

The VHA often has lower occupation turnover rates than private health systems. This 2021 table is a yearly report from Nursing Solutions Inc. which releases data every March in its National Health Care Retention Report. You can see that with roles like CNAs, Patient Care Tech, and several therapist roles, VHA is able to outperform private sector competitors in turnover rate performance.

What is the Workforce and Succession Plan?

The VHA National Workforce Planning Team releases this report every 2 years, outlining workforce facts and labor strategies for providing the best care for Veterans. The plan is a combination of input from medical centers, regional offices (called VISNs, or Veterans Integrated Service Networks), and program offices, with clinical and nonclinical employment data. This report also pulls in VHA’s strategic goals, plus other drivers like diversity, equity, and inclusion benchmarks. All of this information is synthesized into one report that leadership can use for long-term planning.

While building this 2-year report is an achievement, the second half of the battle is to properly communicate results. The National Workforce Planning Team partners with VHA’s Public Affairs organization to build internal strategic communications. This includes leadership calls, participation in VHA large-scale community of practice calls, webinars, intranet web tiles, and articles in VHA publications. Outside of the VHA, the report is shared with external stakeholders like the U.S. Congress, veteran service organizations, and union partners.

The plan includes: VA and VHA strategic direction data, environmental drivers of supply and demand in the labor market, and legislative and government oversight factors which impact workforce priorities and organizational needs. For example, the plan points out the gap predicted for clinicians in the next 10-20 years. The plan also highlights legislation and government oversight factors which will impact future labor and workforce needs. It includes thorough VHA workforce analysis, such as listing the top 19 VHA shortage occupations. It includes turnover rates, demographic information, onboarding metrics, and surveys like employee satisfaction and exit survey results. It highlights info as granular as reasons that specific position groups term employment, which can guide retention discussions.

Additionally, the plan includes workforce priorities and high-focus strategic items to support the workforce, including a current initiative to consolidate VHA HR services. The VHA is in the process of streamlining from 139 different HR offices down to 18 nationally. Other additional plan items include implementation of manpower management principles, and talent development and training programs.

In odd number calendar years, the Workforce Planning Report is released (next report anticipated publication December 2021). But in even numeric years, the team releases a smaller report called the VHA Shortage Occupations Report. In December 2020, VHA recognized the following occupations as the top occupations at risk for shortage:

‘Shortage Occupation’ does not mean a shortage is actually occurring. It could be that forward-looking data points to a position group as being at-risk for a shortage, or there may be anticipation of difficulties recruiting or retaining an occupation group.

“Learning to predict the unpredictable is something we’ll be taking into account when building our future workforce plans” – Shari Florio, Manager, VHA National Workforce Planning

The VHA Workforce and Succession Planning team produces this very detailed report with only 5 full-time employees. Here is the 2020 VHA Workforce and Succession Strategic Plan. Or click here to see the 2020 Shortage Occupation Report. The 2021 VHA National Workforce Planning Report will be available in December 2021.

About Shari Florio

Shari Florio began her career at VHA in 2009 at the James A. Haley Veterans Hospital in Tampa, FL. She entered HR Workforce Succession Planning at VA’s VISN 8, covering FL and PR with 28,000 employees.  Ms. Florio is now Manager of the VHA National Workforce Planning Team, an organization which focuses on promoting talent from within. In her current role, Ms. Florio is responsible for managing the team that informs human capital management and decision-making to meet future Veteran needs and maintain a reliable highly qualified and efficient workforce.

About Catalyst Learning, and how we support the VHA

Catalyst Learning supports the VHA with leadership development curricula for lower paid employees. Catalyst Learning has worked with 95 U.S. VHA medical centers spanning 17 years, supporting entry-level workers employed in GS 1-7 roles with upward mobility tracks.  Catalyst Learning also supports the development of VHA’s Charge Nurse and Assistant Nursing Managers leadership and management skills.

Helping Charge Nurses to Lead During Unstable Times

The role of the first-level supervisory nurse is critical for quality patient care and overall work quality for nursing staff. The role is also very complicated, especially given that nurses often assume the role based on clinical skills, with limited formal leadership development. Solving problems, understanding staff members scope of practice, and dealing with staff needs is a lot to take on, even when times are not turbulent. And in 2021 we know many nurse teams are dealing with staffing issues and turnover. Many teams are staffed with 50% new graduates, more temp travel nurses, burned out nurses, and high acuity patients. These factors, along with turnover of nurses and senior leadership plus new IT processes, add up to many nursing work teams dealing with a continued challenging time.

So how can nurse directors and leadership help charge nurses, as they lead through a turbulent time?

Be transparent about the key issues

Charge nurses do not expect their managers or directors to have all the answers to problems that arise, but they do want the truth. If you are transparent that there is instability and that the team is going through rocky times, that transparency can be a building block for trust. It can also help solve the issues. When staff members have all the information on a topic, they may devise reasonable suggestions or alternatives to solve or improve a problem. Through transparency, nurse teams can mature more quickly.  A lack of transparency can have long-term detrimental effects and lead to less trust or more turnover.

Offer support from more experienced nurses

Young nurses are not looking for authoritarian leadership; they want coaching to help them learn and grow as professionals. Retaining nurses requires adapting to this generation, so make sure the right experienced nurse is providing the coaching. The right coach/mentor can help a young nurse see how their contributions are valued. Mentors can encourage continuous learning, help young nurses to build networks/join professional organizations, and even help teach young nurses about emotional intelligence. For example, University Medical Center (Texas Tech University) offers senior nurse mentors to new nurse leaders. This helps nurses to think about professional development, clarify skills needed for the new role, and understand the goals of the health system. There is nothing in a textbook that can replace real-life experience of a seasoned nurse who has navigated a full career.

Identify struggling staff and plan for early intervention

Be on the lookout for nurses who are struggling with exhaustion, anxiety, or just the reality of how difficult the nursing profession can be. Help show them time management tricks or talk about where the nurse is struggling. If a nurse has a hard time speaking with physicians for example, help them practice those scenarios.

But if a nurse isn’t pulling his or her weight, or causes unnecessary team stress, find a plan to fix the issue. A charge nurse has enough on their plate, so especially during turbulent times, take as much of the team conflict or struggling staff issues off the table as possible.

Remove common leadership barriers charge nurses face

Even when not enduring turbulent times, there are personal and organizational barriers that can hinder success of frontline nurse leaders. Removing as many of these barriers as possible will setup your charge nurses for success. Personal barriers a new leader could face are an inability to see the big picture, a lack of self-confidence, or not delegating work. Remember that your charge nurses may have never led a team before, so talk through these personal barriers.

Leadership barriers could be organizational. These barriers could include staffing issues, a lack of ancillary or clerical support, or a lack of standard operating procedure. It’s impossible for a charge nurse to effectively complete tasks if he or she doesn’t know what the expectations are. If possible, it would be beneficial for charge nurses to meet with administrative leadership to quickly draft a common list of responsibilities. See our related article, 9 Leadership Barriers that a Charge Nurse Faces.

Offer leadership development to prepare nurses for the charge nurse role

Many nurses in a charge RN role have never led a team before and are serving in it because they have the clinical skills. Going from a nurse peer to a nurse leader can cause stress, as it is hard to delegate work to a friend.  So prepare your new nurse leaders with training that can give the insights, interpersonal skills and business knowledge they need to manage a team. Charge nurse leadership development can help a nurse transition from peer to leader, lead quality initiatives, be confident in communications, and help with conflict management.

HCA, the largest private health system in the U.S., made a strategic decision to systematically prepare future nursing leaders for success.  It developed its Charge Nurse Leadership Certificate program and saw that effective development of frontline leaders can improve retention and the delivery of patient care.

Being a charge nurse during turbulent times is very hard. Whether it is staffing, high acuity patients, or employee stress, the role is harder than ever. And we know that the charge nurse role is a first step into nursing leadership, so it is essential that we encourage these new leaders.  It is a win-win-win for leaders to provide stability, transparency, and inspiration.


https://www.emergingrnleader.com/helping-charge-nurses-create-stability-when-staffing-is-turbulent/

“3 Common New Nurse Struggles,” RegisteredNurse.com

“Transparency in Nursing Leadership and Healthcare,” Duquesne University School of Nursing, Rose Sherman, April 14, 2020

“Tips on How to Effectively Communicate to Doctors for New Nurses,” RegisteredNurse.com

“Mentoring Nurses Toward Success,” Minority Nurse Magazine

“For Nurses – Mentoring,” University Medical Center – Texas Tech website

“Helping Charge Nurses Create Stability When Staffing Is Turbulent,” Emerging RN Leader, Rose O. Sherman, May 6, 2021