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8 insights for nurse leaders to achieve success with alternative staffing models

By Carol Boston-FleischhauerLauren Rewers

June 6, 2022

The RN supply/demand imbalance remains a critical challenge for nurse executives working to ensure safe, effective, and efficient staffing. In acute care, leaders are experimenting with various approaches to staffing amidst a continued nursing shortage that shows limited evidence of stabilizing.

In part one of our blog series, I summarized five of these approaches, including building internal flexibility, leveraging technology to support care, embracing team-based care, offloading RN work, and relieving inpatient bottlenecks.

Yet selecting the right approach for your organization is just the beginning. Any staffing or workflow redesign—whether it be a team-based model, technology solution, flexible shifts, or streamlined RN work—needs a solid implementation plan to achieve its intended impact.

In my travels, I’ve spoken to many early adopters about what is (and isn’t) working for them as they lead through various staffing changes. Read on for their insights.

1. Involve staff early in any staffing or workflow redesign

One thing is clear in 2022: RNs are dissatisfied with the environment in which they are practicing, particularly regarding excess workload. While staff may not be as familiar with alternative staffing models and digital tools, the frontline are experts in workflow challenges.

As such, staff must actively participate in every step to design solutions in partnership with leadership. Said differently, any change to staffing cannot be a top-down initiative.  Leaders should leverage existing vehicles for meaningful staff involvement, including but not limited to unit-based councils, revitalized shared governance structures, focus groups, innovation centers, automated surveys, and other IT feedback loops.

2. When introducing a team-based staffing model, don’t forget about your pipeline

Continued RN shortages are driving experimentation with team-based staffing models that position experienced nurses as team leaders overseeing various team members, including LPNs, patient care technicians, ancillary personnel, nursing students, CNAs, and EMTs, as well as novice nurses.

Leaders typically choose team "members" based on local market dynamics, including current and anticipated pipeline. But beyond immediate availability, organizations should partner with secondary education, trade schools, and state regulatory agencies to ensure their pipeline is sustainable and consistent with scope of practice.

3. Select pilot units best suited for disruptive change.

Alternative staffing approaches will disrupt professional, cultural, and organizational norms. As such, the decision of where to pilot is key. Successful pilots require staff readiness, willingness, and flexibility, as well as authentic, unequivocal support by the unit or area leader(s).

Organizations and systems with Dedicated Innovation Units (DIUs) are particularly poised for testing alternative staffing approaches. Those without DIUs should select a pilot unit(s) with a strong track record of adaptability and problem solving, as well as sufficiently stable frontline staff and managers to maximize pilot continuity.

4. Clarify the scope and expectations of all impacted clinical roles

By their very nature, staffing model alternatives require all participants to work "differently" than how they are accustomed. This will include the redesign of core processes essential for care supported by a team, versus an individual. 

Leaders need to redesign each clinical role to complement the work and process changes, as well as how care decisions are made and by whom. The goal is to create a set of roles that are desirable for employees that are integrated with each other to ensure efficiency and team cohesion.

Adherence to all applicable certification, licensure and scope of practice regulations is foundational to optimizing the contribution of all staff assuming redesigned roles and approaches to staffing.

5. Invest in ongoing education for teams impacted most by change

To ensure staff feel comfortable and competent with redefined roles and workflows, organizations need to equip them with the skills and behaviors essential to working in a team. Leaders should prospectively evaluate skill and behavioral needs, as well as plan for periodic observation and debriefings with involved staff to monitor progress and avoid "role slippage."

Late career RNs seeking an alternative to direct care giver roles are ideal candidates to provide "at the elbow" support for impacted units, as well as unit-based educators and managers.

6. Include unions as thought partners

The media is replete with concerns expressed by various unions related to new approaches to staffing.  In some cases, union resistance to even investigating staffing alternatives has been reported. Broadly speaking, the primary purpose of any staffing model solution aligns with union objectives: ensuring safe, effective, and efficient care delivery by providing targeted assistance to RNs overwhelmed with excessive work and insufficient support amidst continued shortages.

Leaders should set the tone for a constructive union partnership by taking the following steps:

  1. Invite union representatives to the table early to clarify the need and intent of the change, share the proposed pilot design and metrics, and confirm options for ongoing union communication.
  2. Work with internal labor relations staff or human resource leadership to clarify the flexibilities within existing contracts for innovation and plan for potential contract renegotiation.
  3. Invest in a prospective and ongoing informational campaign with RNs themselves regarding project intent, their opportunity for involvement, and project progress. Partnering with union representatives on collaborative communication is ideal.  Work to avoid information about project intent and progress only being distributed through union communication channels.

7. Add in safeguards to counteract calculated risk

As an evidence-based profession, nursing leaders are accustomed to relying on evidence to validate practice and process changes. Unfortunately, leaders looking to implement various staffing options to counteract today’s shortages will find a much smaller body of evidence than is customary.

As such, leaders are faced with taking "calculated risks." Absent evidence, leaders must build in a plethora of safeguards to detect and control for any risk to quality and safety. As is the case with any quality improvement initiative, prepare for periodic modifications and changes in approach, including a solid strategy to observe and track impact.

8. Measure, measure, measure—and publish

Prior to implementation, leaders need to identify relevant clinical, employee satisfaction, patient satisfaction, and financial metrics to measure progress. Progress against these metrics should be shared with all impacted employees frequently, along with the C-suite.

Should metric trends suggest the need for modification, leaders must commit to iterating on their approach. At the professional level, leaders should also prepare to share results with their broader network of clinical leader colleagues via informal and formal best practice sharing, conferences, and ultimately peer-reviewed journals.

Please also share your innovations with our team using our Member Portal,  so we can rapidly disseminate as well.

Leveraging your leadership shadow

Nurse leaders may be understandably concerned about overwhelming their staff with more change on top of an incredibly difficult period for the frontline workforce.

But if there’s one takeaway I want to share with all clinical leaders, it’s that work, staffing, and process redesign is essential to re-building the practice environments nursing staff are asking for. Don’t underestimate staff willingness to change; they are looking to leadership for innovation, guidance, and support during this unprecedented time.

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Here are five paths nurse leaders are taking to support safe and effective care delivery.

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