Flexible Service Line Staffing

Dec 06, 2022

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Given that a third of the population could be a specialized patient, we now have nurses provide supervised care during orientation and complete their competency training shortly after orientation ends. This change helped provide adequate staffing because we are not having our contract staff take care of those specialized patients.

Laura Dickerson

Ranked as one of the top heart programs in the nation, Duke Heart Services at Duke University Hospital in Durham, North Carolina, serves more than 65,000 patients a year. In order to provide and maintain levels of optimal care for patients and families, the Heart Center team took a multipronged approach to adequately staff its units. Efforts were also implemented to support a healthy work environment for staff and leaders.

"Due to the impact of COVID, an increase in staff turnover, decreased number of RN/NCA applicants, and use of contract labor staff, we changed existing processes and implemented new ones that supported staffing," said Laura Dickerson, MSN, RN, NE-BC, clinical operations director, Duke Heart Services. "In this article, members of the Heart Center's nursing leadership team are going to share steps we took and the resulting impact to staff and leaders."

Retain Staff by Matching Desired Shifts to Unit Needs

Retention of talented staff was a high priority. The Heart Center leadership team initiated several actions in their service line to help support staff grow professionally and maintain their work-life balance between school, family and their professional growth.

With staff returning to school for advanced degrees, those individuals found it challenging to continue working 12-hour shifts, which is the schedule for all the inpatient units. There was also staff who wished to decrease their work hours due to changes or circumstances with their families due to the pandemic.

Managers collaborated to assist inpatient Heart Services nurses who were looking for alternative scheduling because of school or family to transfer to open positions in the procedural areas. They were able to offer a variety of scheduling options such as eight- and 10-hour shifts, and more part-time options. Therefore, instead of losing nurses who would either have left the service line or the institution altogether, managers worked together to transfer them to procedural areas. This way, they were learning new skills for professional growth, and able to balance school and life obligations with their professional role.

"It has been a great way to fill our staffing needs while supporting work-life balance for staff. Recognizing they may only stay several years due to professional growth opportunities they are pursuing, they bring a wealth of knowledge and expertise to procedural areas that is truly valued," said Nurse Manager Terri DeMuro, BSN, RN, CCRN, CNML. "They're excellent nurses and employees. It's been a positive experience for leadership and the employees."

Nurses in procedural areas have also cross-trained between areas now. It has allowed them professional growth, since they are working in a variety of locations with different disciplines. It's also given the team a larger resource pool to staff those areas.

Allocating Staff Across Multiple Cardiac Units

One strategy to address inpatient staffing is looking at staffing resources across similar units. Four times in a 24-hour period, the nurse managers, assistant nurse managers or charge nurses huddle for a service-line bed-flow meeting. They talk about the census, projected transfers and discharges, the acuity of patients and where staffing needs to be reallocated.

"Within our cardiothoracic (CT) step-down units (SDUs), we first share our nurses with our Heart Center units prior to floating to other service lines, because of the competencies needed. Then, there's always a nurse manager on-call to coordinate the staffing and fill in the gaps throughout the shift as changes occur," said Assistant Manager Ally Shiveler, BSN, RN, CMSRN, CNIII.

"We do look at it from CT to CT, but we also look at it across the Heart Center altogether. We have all of our charge nurses for the Heart SDUs and ICUs attend bed-flow meetings. We do that four times in a 24-hour period," said Nurse Manager Lindsay Botzenhart, BSN, RN, PCCN, CNML.

This helps the team ensure that coverage is equitable so that everyone is staffed appropriately and the nurses have what they need for the types of patients on their unit.

This staffing approach was something the department enhanced in response to COVID. The hospital started with just having designated COVID units, but as they had various surges and everyone felt more comfortable caring for patients with COVID and the use of specialized PPE, these patients were cared for on any unit in the hospital.

Supporting Staff With Less Experience

Like many other hospitals facing staffing shortages, the Heart Center has also seen a decrease in staff tenure. Most staff members have one or two years of experience, and managers wanted to provide them with other resources to help them feel supported.

The assistant nurse managers across all of the Heart Center SDUs created an emergency basics class and a quick in-service that new nurses can take in real time. This training helps provide new staff with extra education on what resources are available and what is expected of them in an emergency. This training includes using the hospital resource of the Patient Response Team for rapid responses, code blues or behavioral emergency events.

"We also have development plans that we've worked on with our education department. They lay out what modules and classes the new nurses need to complete within their first year of being in the Heart Center. It also lays out what opportunities they have once they've completed their first year, including different champion roles, preceptor classes and charge nurse classes to discuss, for their clinical development as a nurse," Botzenhart said.

There are formalized check-ins for new staff members every 30 days for the first 90 days to ensure they are supported.

"It's a standard list of questions. We go over the development plan with them and discuss the Transition to Practice Program. This is a new program started where new Heart Center nurses have classes that they'll take within their first 18 months, and there are options to attend at least one per month. There are also open forums that they can attend with Heart Center leaders and staff members," Botzenhart said. "These are some of the strategies we have implemented to help new nurses feel supported and enhance the expertise of our nursing staff."

"One thing that we looked at critically after the tenure of staff changed and post-COVID surges was the developmental plans. We reviewed the volume of modules we were asking the staff to complete and decreased the number so they could focus on the essential items," Dickerson said. "Additionally, obtaining the ventricular assist device competency used to be completed after 6-12 months of employment. Given that a third of the population could be a specialized patient, we now have nurses provide supervised care during orientation and complete their competency training shortly after orientation ends. This change helped provide adequate staffing because we are not having our contract staff take care of those specialized patients."

Routine Check-Ins

Managers continue to check in with the new nurses, both from a clinical standpoint and also an emotional standpoint.

"We've encouraged them to seek Professional Assistance Services, which is our anonymous counseling support for staff," Dickerson said. "We also have what's called CEO (Caring for Each Other) Services, which is a critical event team. If there's a death of a patient, an emotionally distressing situation or an emergency event, this team can be deployed to support staff with a focus on how staff are doing based on their experiences and helps them identify how they will move forward. This goes beyond the actual clinical debriefing of the event. All disciplines find this service helpful."

Supporting Communication in the Care of Off-Service Patients

During open forums with staff, managers heard that nurses lacked resources for the care of off-service patients. The team responded by creating resources to foster better coordination with other service lines, specifically for the oncology patient population.

"We are seeing some patients on our units who need chemotherapy, so we've provided contact information for nurses and leaders in the Oncology Service Line and management leadership of that area to provide support to our teams when they are in those situations," said Nurse Manager Ashley Frazier, BSN, RN, CCRN. "Oncology nurses are sent from oncology units to help us on our floors. We've also seen quite a few General Medicine patients in our areas that are more complex than what we sometimes see in cardiology areas. We've provided them just-in-time training to support caring for these patients and have collaborated with other teams such as the Pain Team in some complex cases."

Developing partnerships across departments and service lines has benefited the nursing staff, because they now have quick access to the policies, care of equipment and the plan for each patient that might be unique and very unfamiliar to them.

"We heard our teams needed help addressing broken equipment or with escalating requests that were not addressed in a timely manner. We provided a Support Services cheat sheet to our teams to help with this, which lists who to call for certain services. We've also provided connections with other support groups like Nutrition Services if there are issues with our dietary group and meal tray delivery," Frazier said. "It's really nice because our Environmental Services Group now sends out a spreadsheet of who's covering where across the organization for the day or the weekend. So, if our staff needs to escalate something – maybe they're not getting the attention they need right away – with the support of our operations administrator, who's also in house, those resources are available to them."

Standard Processes Across Different Units

The Heart Services Team came together and standardized their champion group so that they could share ideas with one another. Additionally, they created assignment sheets that are very similar between all the stepdown units. This helps staff quickly gather essential information from the assignment sheet when floating to another Heart SDU.

"Additionally, If you have a charge nurse that floats to another Heart SDU, because the same assignment sheet is utilized, the charge nurse feels more comfortable and has a sense of belonging," said Nurse Manager Ciarra Ashley, BSN, RN, PCCN-K, CNML. "We've also created educational activities that are standardized to further assist Heart nurses."

Each Heart unit has an orientation committee that works to standardize the onboarding process in order to keep it streamlined and consistent.

"If we have an onboarding need, a Unit Orientation Committee (UOC) member or Heart leader will assist with completing the administrative skills' check-off with that unit's new staff," Ashley said. "We have received positive feedback from UOC's staff and Heart leaders for this collaborative work."

Leadership Retention

Staff retention is vitally important for the Heart Center staff, and that includes leadership retention - especially nurse managers and assistant nurse managers.

"We support each other and have great teamwork, but we model authentic leadership where we have a lot of autonomy as a nurse manager to make decisions and make our units our own," said Nurse Manager Jessie Legath, BSN, RN, PCCN. "We also have a lot of flexibility with scheduling. If you have an appointment or other personal commitments, there's always another manager willing to cover you. There is no predetermined start and end time, such as 8 a.m. to 5 p.m. Some managers choose to come in earlier around 5 a.m., and some come in later around 8 a.m. Overall, our scheduling model allows us great flexibility with scheduling."

To promote nurse manager well-being and work-life balance, Heart leadership implemented measures to promote flexibility with leader scheduling, including a four 10-hour day option, one work-from-home day per month and flexible start times. Additionally, a structure was implemented whereby one nurse manager covers the service line on a rotational basis every nine weeks. This enables the nurse managers to have coverage after business hours at night and on the weekend and "unplug" from the workplace.

"It provides work-life balance. There's always another nurse manager available for the staff, allowing the others to step away," Legath said. "Managers also report better service line cohesion. The only manager losses over the past several years have been due to retirement and promotion."

These staffing initiatives have helped Duke Heart focus on creating and sustaining a healthy work environment for its team, all while providing exceptional care for patients and families.

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