Dual-Role Staffing Solution

Dec 23, 2021

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The problem that I was trying to solve was nursing turnover and burnout – the overall compassion fatigue and moral distress that we were seeing.

Missy Dorsey

Even before the pandemic hit, Spectrum Health in Grand Rapids, Michigan, was developing a strategic plan to combat the growing nursing shortage and to address increasing instances of burnout among nurses.

As part of the facility’s work, nurse leader Melissa (Missy) Dorsey, MSN, RN, CCRN-K, NE-BC, collaborated with other leaders to develop a dual-role employee initiative that improved nurses’ job satisfaction and enhanced the quality of patient care.

The Issue: Describe the challenge your unit was facing.

Missy Dorsey: The problem that I was trying to solve was nursing turnover and burnout – the overall compassion fatigue and moral distress that we were seeing.

I managed two units, and one of them is the Cardiothoracic ICU (CTICU), which is a 22-bed, highly acute intensive care unit. We provide care to patients with very acute needs such as ECMO, heart and lung transplant and cardiogenic shock. Because of the high intensity, we see here we have turnover for multiple different reasons. As a leader, I really want to try to build a strong team, and retention is part of that. So, I did a deep dive into why these nurses were leaving. Some of the reasons were out of our control, such as CRNA and NP school. The things I felt we could fix included the level of burnout and compassion fatigue my team was feeling. I also started to better understand the new generation of nurses we had. They want variety and change, and doing the same thing all week becomes boring for them. That’s when they start to look elsewhere.

The Solution: What were you hearing from the direct care nurses and how did you address it?

Dorsey: It started with one employee who was talking about his burnout and how he’d seen a lot of tragedy. He also mentioned the impact of doing all his shifts in an environment such as the CTICU had on him as a nurse. So, we started thinking, “Well, what if you did something else?” And he mentioned that the emergency department (ED) sounded like a good idea.

My goal as a leader is to support people in any way possible. If that means one of my employees is going to go to a different department and be a happier employee and be providing better patient care, then I feel like as a leader, that’s my job.

So, that’s kind of where the conversation started, “OK, what is it that you need?” The more we talked about it, the more we realized, “Well, why can’t we just split this?” Our whole goal was to determine how to decrease the burnout of these nurses who are working at the bedside in the ICU.

Implementing the Strategy: Tell us a little more about what you did. How did you implement this strategy?

Dorsey: We started slowly with just one nurse. You have to think about what it means to share an employee; your payroll is going to look different; your scheduling is going to look different. You really have a different level of collaboration with other team members in the leadership role to make this work. I think that’s part of the win of it, too. I have built stronger relationships with my peers all over the institution. I think us as leaders get working in a silo, and we only see what’s in front of us. This structure really pushed us to work together. We had to work out the logistics. What do the holidays look like? What does orientation look like? What does competency look like? Do they need to go to both staff meetings? Having those conversations up front with people was so important.

So, we started with ED. We had that one nurse, and then we really promoted it as a retention strategy for people. It was a solution for those conversations when people come to you and they say, “I’m tired, I’m stressed. I don’t know what I want ... Should I go back to school?" Having those conversations opens that door a little bit before they get to the point that they’re applying to other places full time or going to travel or whatever it is. It’s catching them before that.

When we received interest, we had the employees apply for the dual-role position through Human Resources. I recommend doing it that way, because it keeps it very clean in regard to the system. The FTEs were clean, you had a record of the resume, and it gave you the ability to sit down with a staff member and do an interview. Not everybody is going to be a good fit for this setup.

We were able to hire a few people through Human Resources, and then more people started talking about it. I think people knew that I was a leader who was going to invest in my people, because I really believe that’s the right thing to do. I know it’s not the only answer to nursing turnover, and I think we have a generation of nurses who continuously want to grow. You interview them and they say, “Well, in two years, I want to be done with grad school.” Or, they are taught in nursing school to continue to learn and to push themselves. This is one way we can respond to those nurses who say, “I want to continue to do new things” but also keep a stable workforce.

Lessons Learned: Were there any specific challenges as you were developing the initiative that you want to share?

Dorsey: I think the biggest thing to consider is what that orientation looks like. For example, I had a nurse who was going to the ED, and I had to give him up for three months because he had to go and orient there. You have to think as a leader, “Is this person ready to step away for three months?” I expect my nurses to be here for at least two years before I will say, “OK, you’re ready to go do a dual role.” They need to be proficient and confident in their skills before I feel like I’m confident in saying, “You can step away for three months or whatever your orientation is going to look like in this other space.”

Sometimes I had a nurse manager from ED come to me and say, “Hey, just so you know, we’re going to take them for three, four months, and they’re going to be in my space. So, you will have to fill the gap in their holes or their schedule.” It’s important to consider the complexity of each environment, and if they’re both very complex, what those competencies will look like. For instance, in my area, we have a lot of competencies because we do all of the devices. So we have the heart and lung transplants, and we do the ECMO, CentriMag and Impella. So, when you have those devices, you need to keep up on them.

Maintaining those, plus whatever that second environment looks like. It’s so important for the employee to know the expectations up front, because it probably will be a little bit more work for them.

The Outcome: What kind of changes have you seen as you’ve rolled out this program?

Dorsey: I am amazed at the success to be honest. We had 22 nurses in this cohort, and we had only one of those people turn over. You still have those who say, “I’m going to go to CRNA school [or] graduating with my NP.” But of the cohort, only one person left in that timeframe. Then in 2021, we were up to 24 and two of those people have left.

In addition, we surveyed all the respondents and asked, “What was your intent to leave? What was your decrease in burnout and overall job satisfaction?” Their overall decrease in burnout was 100% by all the respondents, which to me was huge. That was our goal; how do we make these nurses more satisfied in their job? In turn, we will retain them and decrease their burnout, which will support better patient care.

I think this initiative supports a better culture in the unit and in the organization. In addition, it helped us develop a strategic staffing plan and better clinical skill sets and leadership collaboration.

This program also helped create more collaboration among the managers. We talked more, whether it was in person on email or via Zoom, because we shared an employee. We shared that relationship together with that person. So, we had to work together to support that employee through their time with us. You just naturally build a relationship because you learn a little bit more about each other, and it gives you that empathy that sometimes we lack when you’re so focused just on your own space. I think ED and ICU is a really good example of that very different level of care.

When we did this, it built relationships between the team members, because you had somebody who worked in both spaces, but also the leadership team, because we’re working together on schedules. It pushes you out of your normal comfort zone. My normal peer group is my ICU colleagues and my director and some of our cardiothoracic non-ICU spaces. Now, I work closely with the Labor and Delivery (L&D) manager. So, now when I have a mom who’s in the Cardiothoracic ICU, I have that collaboration with the L&D manager that I can reach out to. For example, we have two L&D nurses who work in CTICU and L&D. We have been able to provide a different level of care to moms who are in CTICU when these nurses are here. And vice versa; we’ve been able to keep sicker moms in the L&D, because those nurses are there. They have a different level of care.

Advice to Nurses: Do you have advice for someone who is considering meeting their staffing challenges with a program like this?

Dorsey: It’s really, just to start slowly, I think, and have your expectations set. What do the holidays look like? What do the weekends look like? What is your orientation going to look like? You might need to collaborate with your educator first and find out what they expect. If you were to take somebody from a different environment or if you were going to allow someone to step away, what does that look like to you? Therefore, when you do start to meet with other departments or your staff members, you have all that information.

There are still going to be things that come up. Maybe you didn’t think about [some things] when you started, but I think if you have a good relationship with the team member and the other leadership, you work together and you figure out the best strategy.

It’s still giving nurses what they want – that stretch, that “I want to continue to grow” desire, while still keeping them at the bedside. This is especially important for the newer generation of nurses, and I think we have to start thinking that way. We need to think about where nursing is going to go in the next 10 years, especially with staffing changes as a result of the pandemic. We need to respond in a way that allows nurses to keep growing, changing and learning different things.

Do you have a successful staffing solution that works in your unit or facility? We want to hear from you. Submit your solution.