How Valley Children's addressed leaders' perceptions of unsafe staffing

In 2015, Valley Children’s engagement survey showed a low score on the driver “My unit or department has enough staff.” In response, and as part of their 10-year strategic plan between 2015 and 2016, Valley Children’s’ increased staffing levels across the organization. Leaders believed this would help with staff engagement—especially the driver “my unit or department has enough staff.”

But that didn’t happen. In the 2016 engagement survey, that driver had fallen, despite adding FTEs. These results surprised leaders. So, to understand what was behind staff perceptions staffing levels, they turned to their frontline leaders.

Valley Children’s director of workforce engagement and development revamped an existing monthly leadership meeting. They shifted the agenda from mostly didactic presentations to a working session on addressing staffing-related distress. Participants included charge nurses, managers, and directors.

To run this exercise, participants were split into small working groups. From there, they used the discussion prompt “When was the last time your unit felt under-staffed?” to open the conversation. Participants identified specific times when their unit felt understaffed and shared their stories in their small groups. While doing this, the facilitator asked participants to discuss the staffing details that day, such as: What was patient census? The skill mix that day? Did anyone call out sick?

This helped the group assess if their unit or care site was truly understaffed—and warm-up for the next step: root-cause analysis.

Once leaders had specific examples of when they felt short-staffed, the facilitator asked them to consider other variables that could influence staffing levels, such as PTO or non-top-of-license work. The goal was to build a list of factors but impact staffing that aren’t related to number of staff. Below are root causes identified by leaders at Valley Children’s, other than actual short staffing.

• Poor attendance
  
  
• Calling out last minute
  
  
• Tardiness
  
  
• Too many people on PTO at once
  
  
• Lack of communication across shifts
  
  
• Voluntary turnover
  
  
• Seasonal census peak in the winter
  
  
• Lack of cross-training

Given this list, it is easy to see how leaders and staff felt like their unit didn’t have enough FTEs, even when it did. This brainstorming helped leaders think differently about the problem and see that other factors can make a unit feel short-staffed, even when it isn’t.

If running an exercise like this, we recommend having relevant data on hand to share with leaders. For example, at Valley Children’s, leaders reviewed the impact of additional FTEs on current engagement scores. This data helped leaders see that adding FTEs did not improve frontline perceptions about staffing. Other helpful data may include: staffing benchmarks, ratios, and clinical outcomes for unit or care sites.

Using the brainstormed list of root causes, the facilitator and participants identified three common themes: efficiency, accountability, and actual lack of FTEs. Following the initial working session, Valley Children’s created template action plans for each of the three themes for frontline leaders to use.

At a subsequent working session, leaders then selected the action plan that best aligned with the staffing challenges on their unit or department and tailored it as needed. For leaders who needed help selecting the right action plan for their unit or department, Valley Children’s developed a guide to help. Below is a sample of this guide.

• The most common action plan was efficiency. Most leaders who initially thought their units needed additional FTEs realized the root cause was actually an efficiency issue, such as redundancy in processes, workload prioritization, or top-of-license practice.
  
  
• The second most common action plan was accountability, including ensuring staff are reliable and dependable when scheduled to work, and examining scheduling practices.
  
  
• Finally, some leaders had legitimate staffing concerns. Despite the staffing increases, there were a few pockets of truly understaffed units. The third action plan was for those units that had legitimate business case for requesting additional FTEs.

If needed, leaders selected more than one plan. Following the working sessions, leaders shared their action plans with staff to engage them in the proposed solutions.