With an impending nursing shortage, organizations need to take every reasonable step to retain staff. Right now, experienced nurses are leaving because their roles or shifts conflict with their personal safety or home life. This trend, in combination with expected baby boomer retirements, will leave organizations with fewer experienced staff. Retaining these nurses, albeit in nontraditional ways, is necessary to provide safe patient care. Therefore, all organizations need to consider shorter shifts and roles that retain this subset of staff who can’t otherwise continue to work.

This isn’t a new strategy, as many organizations have developed enticing options to keep late-career nurses in practice longer. But as more late- and mid-career nurses leave, provider organizations must scale this strategy to all experienced RNs who need flexible work options.

The key to making this work is to first understand what shift lengths and types of roles staff need, and then create roles that fit and balance patient safety. To gather information on experienced staff needs, consider using existing channels such as shared governance meetings or surveys. Responses will vary across facilities, units, and individuals, so be expansive when gathering this information. Once you have this information, you can design roles within the confines of their needed hours that ensure top-of-license work without increasing patient handoffs. For example, create a short-shift float pool of nurses to work 4-, 6-, or 8-hour shifts, or design remote roles for more experienced nurses to oversee care virtually.

Keep in mind, the majority of the workforce will still work 12-hour shifts. It’s good for patients, and many nurses still prefer working longer hours across fewer days. Rather, supplement traditional shifts with shorter options for the subset of experienced nurses who need them. Our best estimate is less than 10% of nurses will need or want these nontraditional roles.

As more experienced nurses leave the workforce early, so will their deep technical expertise. Most organizations felt this challenge acutely with Covid-19—there were widespread shortages of nurses with necessary technical expertise, such as operating ventilators and proning patients. While Covid-19 surges were an outsized example of technical shortages, we expect it will be more difficult in the years to come to find enough experienced nurses with the right expertise to staff certain units. Without intervention, organizations should expect a tremendous increase in labor costs due to agency labor and chronic vacancies or dips in quality.

Rather than trying to recruit from the scare supply of experienced nurses, organizations need to cross-specialize already employed nurses with similar technical skills so they can be redeployed to other units and care sites when needed.

The most important part of this strategy is deciding which nurses to cross-specialize. Start by looking for synergies across units and care sites where at least 50% of the necessary technical skills align. For example, settings that require regular use of ventilators, telemetry devices, or radiation therapies. For some areas, there are straightforward synergies across inpatient and outpatient settings. For example, an organization we recently spoke with needed staff with expertise in chemotherapy and bone marrow transplants to fill vacancies in their outpatient bone marrow center. In response, they created split positions that redeployed interested nurses from their inpatient bone marrow transplant unit to the outpatient settings as needed.

But don’t overlook the possibility for less obvious synergies. For example, sharing nurses across short-stay units, PACU, and the OR. OR nurses have seen success in PACU units due to their deep knowledge of patient’s post-surgery needs.

Over the long term, large or growing health systems will need to supplement this work by growing their pipeline of technical expertise. One of the best ways to do this is through targeted fellowships.

Most organizations used team-based staffing models in response to Covid-19. This was for good reason; it helps to address experience and specialty shortages during crisis. Moving forward, organizations should be prepared to use team-based approaches more regularly with an experienced nurse leading the team.

A team-based approach can take many forms. But regardless of the skill mix, number, or types of roles on the team (including if you use other licensed or unlicensed staff), there are two guiding principles to keep in mind when implementing team-based care:

• First, elevate experienced nurses to the head of the care team. Ideally, this experienced nurse is proficient or expert according to Benner’s stages of clinical competence. These nurses are best positioned to lead the care team, own coordination for all patients under their purview, and serve as a liaison with interdisciplinary colleagues. The rest of the care team should be created based on patient acuity, preferences, and what staff are available in your market.
• Second, clearly define the other roles on the care team. Each team member must have clear responsibilities down to the task level, if possible. Competent RNs are best suited to provide advanced patient care and support expert RNs with care planning, patient education, and discharge. Novice nurses who are still learning the ropes benefit from providing basic patient care and assessments. Beyond general competency-based roles, consider how to deploy LPNs or CNAs to complete specific tasks.

Bottom line: the key to team-based care is delineating roles by expertise. This means getting comfortable with there being more than one RN job description—ensuring all levels of nurses are practicing at the top of their license. This does not mean roles have variable compensation or value. Rather, the staffing model maximizes the different skills and expertise of each nurse.

We implore nurse leaders to experiment with staffing models in the coming years. There is no silver bullet. If expert-led care teams are not the right fit, experiment which other staffing models to find the what’s best for staff and patients.

Most organizations rely on float pools as their main source of flexibility. This means only a small percentage of the workforce has flexibility built into their role. Organizations’ biggest opportunity to meet changing staff needs and address staffing demands is to extend the principles of the RN float pool to the entire workforce—moving from flexibility for a few to flexibility for all.

That said, flexibility for all doesn’t mean every role in the organization must be flexible in some way. It means nurses have the opportunity to work in a more flexible role if they need or want it. And nurse leaders can move staff to meet demand without “redeploying” nurses from their home unit. In addition, float pools will continue to serve an important role as a safety net for unanticipated changes in supply and demand, and organizations should continue to refine them as system needs evolve. If you need guidance on how to do this, read our take on float pools.

There are many ways to move non-float RNs across settings, including: blended roles, system-wide scheduling, or rotating staff across sites of care. The key to this broader flexibility is enabling non-float RNs to regularly practice across multiple settings.

To enable this, flexible roles must work within the organization’s current structures and processes. Below are some of the questions to consider when deciding which flexible roles to pilot. The goal is to answer a resounding yes.

• Where do you have the most momentum from Covid-19? Most organizations generated momentum here during the pandemic, deploying non-float RNs across a variety of locations to respond to surges. Consider where you have seen early successes and continue this work.
• Do you have access to real-time visibility into staffing and demand? This is easiest when enabled by technology. At a minimum, identify how units can easily communicate changes in staffing and patient demand to deploy RNs across settings when needed. If you lack this capability now, that doesn’t mean you can’t execute this strategy. Rather, begin to work on this now to enable visibility in the future.
• How will flexible roles impact managers’ scheduling practices? If the new roles make scheduling harder, there needs to be a clear benefit for the manager (beyond organization-wide benefit). Consider how any tactics you pursue will impact scheduling and seamlessly incorporate that into manager processes. In the long term, make appropriate investments into enterprise-wide scheduling technologies that will improve manager workloads and enable seamless scheduling across locations.
• Do you have process standardization across the organization? To move staff across units or sites requires a baseline level of process standardization. If not, staff will struggle with everything from following protocols to finding supplies.
• Have you created supports that allow nurses to safely practice in other settings? If staff feel unsafe practicing outside their home unit, even the best designed flexible role will fail. Flexible roles need to be accompanied by appropriate cross-training and support, be that peer mentors, unit information packets, or clarification of baseline expectations of the core nursing competencies across settings.

In addition to enabling flexibility, think about cadence. This isn’t about fulfilling a once-a-month quota, but rather about moving around at a regular cadence to give nurses consistent exposure to other parts of the organization.

This strategy is ambitious and will take years. Organizations will iterate and progress over time. In the short term, early success and learning will help you respond to fluctuations in demand and staff using less agency labor. Meanwhile, you are building the blocks to create a nursing enterprise comprised of system-citizens.