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May 20, 2022

Changing the structure of nursing is essential

Daily Briefing

    In the third year of the battle against Covid-19, the nursing workforce is in a dire state. But there is something health leaders can do.

    Radio Advisory's Rachel Woods sat down with Advisory Board's Monica Westhead and Carol Boston-Fleischhauer to discuss what health leaders can do to support their nurses and why changing the structure of nursing is essential.

    The nursing shortage, discussed: A conversation with Advisory Board's top nursing experts

    Read a lightly edited excerpt from the conversation below and download the episode for the full interview.

    Rachel Woods: So the situation is bad. We don't have enough bedside nurses, or we don't have enough nursing expertise. This is where people start to use the word crisis. I'm not sure if crisis even begins to cut it when we think about what nurses have been going through. But if I'm honest, we've been having a conversation like this before. We've about how to help nurses, how to support nurses. And yet, we are still here using words like crisis. The question that I'm getting from health leaders is, "What the heck am I supposed to do now? How am I supposed to support these people?"

    Carol Boston-Fleischhauer: The foundational recruitment of retention practices that I think the entire industry is keenly aware of, we got to keep going with those. I mean, we have to keep going with what we know can solidly recruit and retain staff in our organizations.

    However, we've got to get at root cause as to why people are disillusioned with providing care in an inpatient environment. When we take a look at the disillusionment, it really comes down to employees saying, "I want much more flexibility in my work environment because I need it. If I can't get it from you, I'll go elsewhere."

    Secondarily, "I want an organization that really cares about my personal well-being." And third, I want an organization that will help me rekindle my sense of feeling valued and feeling as if I'm contributing to the purpose that I committed to in the first place when I became a nurse. These are tough issues to get at, but they're deeper than the standard recruitment and retention practices that we've talked about historically.

    Monica Westhead: Carol, I would agree with everything you just said. I would also add, nurses want professional development opportunities. And I think a lot of nurses leave the bedside because they want to pursue advanced practice. For many of them that is their career goal. But in other cases, it's because they're looking for some kind of professional development or professional growth that they don't necessarily see us able to provide to them within the current structure at the bedside.

    The other piece of the puzzle, I think, is support staff. If you are in a situation where you've got so much turnover and can't fill roles in the CNA ranks, that work has to go somewhere. In many cases, that work is going onto the RNs. So it's important to remember, as we think about RN turnover, RN staffing, that RNs are one piece of a very complicated, interdependent staffing puzzle.

    Woods: All right, let me admit to both of you, I'm having a little bit of déjà vu here because I'm feeling like we've talked about this before. We talked about the challenge that nurses are cleaning up rooms, and they shouldn't be doing that because there is no support staff, like you said, Monica.

    We've talked about the fact that we need to truly show nurses that they are valued and not just throw them a pizza party. And we've said over and over again, that nurses need the kinds of flexibilities that fit into their world. And frankly, fit outside of 12 hour shifts that have existed since the dawn of nursing. Why am I having déjà vu? Why are we still out here telling leaders that they need to make these changes?

    Westhead: I think these are very difficult changes to make. It's not that anyone doesn't know that we need to provide nurses more flexibility, that we need to rethink what those roles look like, but it is just a lot more challenging to actually do those things than it is to rely on the smaller pieces that I think leaders have been trying to use for the last few years, hoping that eventually this would go away. I'm not optimistic that the shortage is going to go away without some significant changes in the way that we structure nursing roles.

    Boston-Fleischhauer: I guess I'd go one step further. I would say this is more than just C-Suites feeling challenged by this. I think executive teams are now just coming to terms with what we're talking about in terms of a dollars and cents investment.

    When I'm talking dollars and cents investment to support the workforce moving forward, it's beyond compensation. It's taking the time that you need to put in place a significant process and working through any changes to make certain that the registered nurses, and other care providers who are being asked to staff work differently, are supported with change management, to be successful in working in different models and in a different roles.

    Woods: Wow, you are exactly right. Because if I think back to the last two years, there were certainly moments where leaders pushed for flexibility, because they basically had no choice. But thinking about embedding flexibility into the career of a nurse, as just one example of something we need to do, that's a huge operational undertaking. How do leaders actually go about doing that?

    Boston-Fleischhauer: Well, think about this for a minute. When we think about staffing an inpatient unit, we have relied on predictable 12-hour work schedules and predictable stable roles for one unit, for a registered nurse to work in.

    So if we're talking about flexibility in, for example, shifts, where we have four hour shifts or six hour shifts, we are totally disrupting the workflow of the standard 12-hour shift. Working as a registered nurse over the years, I had a schedule in my mind as to what I was supposed to do at 9:00, at 10:00, at 11:00, at 12:00. If you're interjecting different shifts into the 12-hour model, then you've got to have different handoff processes.

    You've got to have different relationships and operational supports between the staff that are coming and going in between that 12-hour model. This is hard to do. We've talked about it a lot, but this is really hard to do.

    Westhead: I also think shift flexibility is certainly one of the most important angles of flexibility, but another piece that a lot of health system leaders don't necessarily think about is where people are working. Flexibility in terms of care setting, in terms of actual job role, I think a lot of leaders are still thinking about staffing based on individual units. So, "Do I have enough staff to run this med surg unit on this day?" Versus more system oriented thinking.

    Because when you think about what nurses want, you may have some nurses that have not thought, for example, about working in home health, but that's actually a really good fit for them because of the schedule flexibility, or because of the difference in commute. Or working in a skilled nursing facility might be good for people who are looking for a specific amount of autonomy or leadership that they might not find in an inpatient unit.

    So I think we talk about flexibility, we don't want to lose sight of what that means in a broader sense. It certainly means shift length, but it also means, what type of work are they doing and where are they doing it?

    Boston-Fleischhauer: From my perspective, where I'm hearing most of the concern right now is not so much the allowance of registered nurses to work in other sites or settings within the care system, or broadly defined, as much as, "How do I keep registered nurses in the inpatient setting as long as is possible?" Because that's the biggest pain point that I think hospitals and health care systems are collectively saying is at a crisis level that shows no signs of reversal.

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