Even as Covid hospitalizations sink to the lowest numbers since March of 2020, inpatient employers struggle to maintain adequate staffing levels. 2021 RN turnover rose to 18.8% in 2021, up from 15.5% in 2020. This is the highest turnover rate in the survey's 15-year history, as well as the biggest year-over-year spike. And concern over staffing extends far beyond workforce leaders—a recent survey by ACHE ranked personnel shortages as the top concern of hospital CEOs, with RN shortages noted as the most pressing.
Guide to inpatient nurse staffing models
In 2021, my team and I sought to identify strategies that slowed the exodus of bedside RNs. And while organizations must continue their recruitment and retention efforts, they won't be sufficient for many markets that continue to experience supply-demand imbalances. Instead, leaders must take a multi-pronged approach that includes identifying staffing solutions to safely deliver care with fewer RNs, while working to reduce turnover and fill vacancies.
In the first of a two-part report on staffing solutions, I've outlined the five key paths that top performing CNOs are taking to support safe, efficient staffing amid continued shortages. In part two, I will share insights from early adopters on how to effectively lead through staffing changes.
The 5 paths to support safe, effective staffing
1. Build internal flexibility
Employees across many industries name workplace flexibility as key to their retention. In health care, flexibility serves two functions: responding to growing staff asks for employment flexibility, work-life balance, and skill development, while creating mechanisms for organizations to safely flex staff to sites of care with greatest need.
True nursing workforce flexibility requires employers to move beyond float pools to include role, site, and schedule variability. Read our report for four strategies to embed flexibility within the RN workforce.
2. Leverage technology to support care delivery
Despite growing interest in digital health solutions, most innovation remains focused on increasing ambulatory access (e.g. virtual visits) and streamlining physician workflow. But this narrowly defined digital strategy is a missed opportunity to use technology to staff more efficiently.
Leaders should leverage virtual technology to augment staffing and monitoring support, particularly in short-staffed units or those staffed heavily with novice RNs. We've seen organizations do so in two ways:
- Introducing an inpatient virtual RN role to provide expert support while shifting the bedside skill mix, and
- Creating a hub of expert and/or specialized RNs to provide support to rural or short-staffed sites.
3. Relieve inpatient bottlenecks
Debilitating SNF workforce shortages cause acute discharge delays, which in turn exacerbate bedside staff stress. If hospitals support SNFs to keep beds open and smooth care transitions, they can meaningfully reduce inpatient staff workload.
For example, WellSpan Health partnered with SpiriTrust Lutheran to open more than 30 SNF beds that were closed due to staffing shortages. WellSpan redeployed 24 LPNs for 3-week assignments to staff those beds until SpiriTrust replaced the LPNs with agency labor.
Through the partnership, Wellspan and SpiriTrust increased average SNF daily census by 15 patients per day. WellSpan will continue to support this program as necessary by redeploying staff within their internal staffing agency.
4. Embrace team-based care
Many organizations are unable to hire the number of RNs required for primary nursing models. Team-based models—in which an RN leader oversees a combination of less experienced RNs, CNAs, PCTs, or other staff—is a feasible alternative. Team-based models allow RNs to practice at top-of-license, while offloading some of their workload throughout the team within scope of license and policy guidelines.
The question for many organizations isn't if they should adopt team-based models, but who will make up the care team—especially as CNAs and other roles are also in short supply. Absent a healthy pipeline of traditional inpatient nursing support roles, leaders can consider creating new roles or deploying clinicians not typically found on inpatient units (e.g. EMS staff, pharmacy technicians).
5. Offload RN work
As workforce shortages at all levels persist, RNs can become a "catch-all" for all unmet non-professional work. This increase in workload, combined with a blurred scope of practice, is linked to rising RN intent to leave. To offload excess work, leaders should consider implementing team-based staffing and/or the creation of specialized roles that assume total responsibility for core functions (e.g. admission, discharge, etc.)—while more generally streamlining inefficient processes.
Ultimately, there is no one-size-fits-all solution. Executive teams will need to consider local market dynamics, their projected RN pipeline, resources, organizational culture, and state scope-of-practice and/or other regulatory guidelines. Organizations should also invite the frontline to participate in identifying staffing solutions, in addition to union representatives (for organizations with a collective bargaining agreement).
In part two, we will share insights from early adopters who have journeyed down these paths. If you have any questions in the meantime, please contact my team directly through our Member Portal.
Nurse leaders are charged with deploying staffing resources to support the delivery of safe, high-quality, and cost-effective patient care. Over the years, organizations have experimented with a number of different staffing models to meet the needs of their changing patient populations and care environments.