How Covid-19 will impact the nursing workforce

You can buy your organization some time to address the experience-complexity chasm if you can retain your most experienced nurses across the coming months. Your best retention strategy right now—for nurses of all tenures—is offering comprehensive emotional support to mitigate the pandemic’s impact on already high levels of stress and burnout.

Health care has a long-standing “I’m fine” culture; clinicians routinely deprioritize their own needs and rarely ask for support. Covid-19 hasn’t changed this tendency, and the additional stressors brought on by the pandemic make it far more likely nurses will burnout and leave. So now is the time to audit your emotional support resources both in terms of what you’re offering and how you’re advertising them.

Offering emotional support must go far beyond publicizing contact information for your employee assistance program. Comprehensive emotional support must include targeted resources for trauma and grief, moral distress, and managing routine job-related stress. Nurses must be able to tap into support through a wide variety of channels – a smartphone app, for example, will provide welcome relief to some, but not all.

The way you position emotional support is as important as the resources themselves. All leaders must directly address clinicians’ “I’m fine” attitude to convince them to lean on the support you’re offering. Do not underestimate the impact your personal vulnerability as a senior leader can have on encouraging nurses to seek needed support. Share the ways in which you are “not fine” as a result of the pandemic, and how you’re prioritizing your own emotional health.

Pandemic or not, no new graduate nurse has ever emerged from 12 weeks of onboarding fully competent and ready for independent practice. New grads are routinely assisted formally and informally by experienced nurses working the same shift. But as more nurses retire, there are fewer and fewer experienced nurses who can lend a hand informally to guide a novice nurse during their shift. Organizations must overhaul the first year of practice to ensure new grads are better prepared to practice on their own.

The secret to accelerating the transition to competent practice is ruthless prioritization. New grads can provide safer care if they have full mastery over a small set of skills, rather than a weak grasp on a wide range of skills. Leadership teams can agree to this principle in theory, but in reality, it’s difficult to resist the temptation to cram “just one more” skill or competency or module into onboarding. As a result, new grads typically fly through onboarding without the time and space to master a small set of core skills before adding new ones.

Slowing down the first year is especially important to do now as patient volumes continue to fluctuate. Unpredictable patient volumes (both in terms of census and type of care needs) make it significantly harder to give new grads consistent hands-on practice. Expect them to need more time to get the right number of repetitions to learn a given skill.

We urge all organizations to slow down the first year. Start by closely evaluating just how much your organization is trying to teach new grads, when and where the teaching happens, and who does it.

Nearly 40 years ago, Patricia Benner codified the stages of clinical competence for a nurse. Reaching the expert stage requires several years of delivering the same type of care. RNs who reach this stage—typically after more than a decade of practice—draw on highly valuable knowledge, skills, and intuition when delivering care and coaching other nurses. Expert RNs are scarce, both because it takes so long to develop this level of mastery and because experience alone is no guarantee that a nurse will achieve expert-level competence.

Historically, there have been few distinctions on paper between novice and expert nurses’ job descriptions, despite the very different skill level that expert nurses bring to the role. As the number of expert nurses declines due to retirements, organizations must do all they can to scale the impact of remaining expert nurses beyond the patients they care for directly.

There are two ways to scale the impact of expert nurses. First, elevate their role on the care team. Shift from a staffing model where each nurse carries a similar patient load (regardless of competency level) to one where an expert nurse formally leads a team of less experienced nurses.

Structuring a team this way requires upfront investment to assess each nurse’s competency level and indicate it in the scheduling system. Successful implementation also requires identifying nurses who are not only experts but also have the potential to be strong team leaders. Experienced nurses used to providing direct care will need training and support to delegate effectively in their new role.

The second way to scale the impact of expert nurses is redefining how they support new grads. Expert nurse preceptors should work with new grads only on advanced skills later in onboarding, while less experienced preceptors teach baseline skills earlier in onboarding. This tiered preceptor model allows more new grads to benefit from expert preceptors’ experience than if expert preceptors worked with a smaller set of nurses throughout their full onboarding. Expert preceptors can further scale their impact by coaching less experienced preceptors.

Experienced nurses’ remarkable willingness to flex where, when, and how they work during the pandemic has enabled health systems to quickly expand their Covid-19 capacity. Nurses are functioning as members of a system-wide workforce, which has enabled leaders to deploy experienced nurses to match variable patient needs across the organization.

Leaders must take advantage of this temporary shift in frontline nurses’ perspective and use it to reinforce nurses’ identity as system citizens first, and members of their unit/care site second. This shift in identity underpins a system’s long-term ability to close the experience-complexity chasm by redistributing experienced nurses across the system. Local site leaders will also need to fundamentally shift their thinking about their team, considering their team members “on loan” from the system rather than permanent staff.

To be clear: these shifts in culture and identity take years to achieve. So we urge all organizations to define a short, mid-, and long-term game plan to build system citizens. To help, we’ve evaluated several tactics on the next page based on their ease of implementation and potential impact on shifting the organization’s culture.

There are three “no-regrets” moves to pursue if you are trying to build a system-wide culture:

• A system-wide float pool gives you greater flexibility to match nursing experience to fluctuating volumes of complex patients. Equally important, creating a system-wide float pool starts building the organizational foundation needed to seamlessly flex nurses. You’ll need to tackle issues such as standardizing roles, developing an IT infrastructure to capture staffing needs, and forging strong relationships between unit/site managers and float pool managers.
  
  
• Cross-continuum shared governance can help expand participating nurses’ perspective beyond their current site. Integrating inpatient and ambulatory shared governance councils gives nurses the opportunity to identify, adopt, and reinforce shared standards across care settings.
  
  
• Reducing the backfill time for internal transfers helps remove one of the major practical barriers to staff mobility. Managers are understandably reluctant to encourage star team members to pursue roles across the system if they don’t know when they’ll receive a new staff member for their vacant slot.