Innovative Staffing Models to Overcome Nursing Shortage

Paul Anderson: Welcome to Smart Healthcare Safety from ECRI, the most trusted voice in healthcare committed to advancing effective evidence based care. I'm your host, Paul Anderson. And for more than 10 years, I've overseen our patient safety, risk and quality membership programs here at ECRI. Tens of thousands of healthcare leaders rely on us as an independent, trusted authority to improve the safety, quality and cost effectiveness of care across all healthcare settings worldwide. You can learn more about our unique capabilities to improve outcomes at www. ecri. org. Today, we're taking another look at shortages in the healthcare workforce. Healthcare has faced workforce shortages in the past, and even before the COVID-19 pandemic made things even worse, the American Nurses Association and the US Bureau of Labor Statistics forecast the retirement of more than half a million registered nurses by the end of 2022. Our guests today are Claire Zangerle, chief nurse executive of Allegheny Health Network in Pittsburgh, Pennsylvania, and Erin Todd, nurse manager of Five North at Jefferson Hospital, also part of the Allegheny Health Network. Claire, I'd like to start with you. And when we think about healthcare workforce shortages and specifically nursing shortages, I know that you've been leading development of a staffing model that we've called blended staffing. So can you describe a little bit about what that is?

Claire Zangerle: Sure, thanks Paul. Thanks for having Erin and I today. We're excited to talk about some of the innovative things that we are doing during the most challenging time of my nursing career, which is during this staffing challenge. So, even before the pandemic, as you said, we were faced with staffing shortages, but nothing compared to what we have now. Before the pandemic, I was underwater by about 250 nurses. Today, I'm underwater around 1, 200. I would gladly go back to those days when it was 250. So, coming to the table with creative solutions has been a very high focus for us. And one of those solutions that we've come up with, and we actually even started this before the pandemic, because it was opportunity for us, is bringing LPNs back to acute care. Back in the day in the'80s,'90s, 2000s, we said," LPNs, thank you for your service. Go ahead and go to the LTACHs, go to rehabs, go to post- acute care because you know what? We've got it from here with the RNs at the bedside." A lot of it had to do with Magnet designation and Magnet saying you had to have BSNs at the bedside. And yes, there is evidence, and we believe in that evidence that having BSNs at the bedside is absolutely better for quality, safety and efficiency. However, in light of the shortages of nurses, we look to a blended model. And now, some of us may remember this as team nursing and there's not much of a difference. We just rebranded it into blended nursing because we feel blended is a better description of the team. And for us, blended nursing is utilization of a registered nurse as a team leader, an LPN as a member of the team, and a nursing assistant slash patient care technician, as a member of the team as well. So, that team takes on a cohort of patients and support each other as they're supporting those patients at the bedside in their unit. There's really not a big difference between team nursing and blended nursing. But I can tell you, with the different generations of nurses that we have, if I said team nursing to one group of nurses, they'd be like," Yeah, we've done that for years." Blended nursing is new to a different generation of nurses, but essentially, they're the same thing. And it's all about the teamwork. I think that's the essential piece of this entire model.

Paul Anderson: Want to take a quick step back, actually, just for a moment. I wonder if you could define briefly for our audience who may not know, what is the difference between a BSN, a registered nurse, and an LPN?

Claire Zangerle: So, a bachelor's prepared nurse is a nurse who's had a more education, more formal education. They have a four year degree. A licensed practical nurse has more technical training and it's a certification and a licensure in that vein. There's no associate's degree or bachelor's degree connected with that. I guess the LPN, you could say is right between the skillset of a nursing assistant, and a registered nurse. And they have, every state, an LPN has scope of practice and across the nation, those scopes of practices are very different. We focus because our footprint is in Pennsylvania, Western Pennsylvania, and a little bit north of us. And even into Western New York, we focused on scopes of practice for those areas, so that we knew what an LPN could and could not do within their scope of practice. So, they're very different disciplines, but they certainly complement each other. And another reason that we focused on LPNs is because we weren't getting enough nursing assistance. We had to relieve the workload of the registered nurse, and by introducing that LPN back into acute care, that also helped relieve some of the pressure on the nurse to get every single thing done, and allow our nurses, our registered nurses, to practice at the top of their license.

Paul Anderson: You anticipated a couple of my questions there. I was going to ask about the scope of LPNs really being set at the state level. And so, you mentioned that, and the phrase that I was thinking of, the more you were talking was that concept of practicing at the top of their license. So, I guess my question is when you've got this team of RNs and LPNs and nurse assistants who are working together, other than what's defined by state scope of practice regulations, obviously those are what they are and we have to work with them. Are there other non- negotiable elements to how that teamwork is split up, that you say," Okay, no matter what else happens, this is something that I need an RN to be doing." Whether it's for a safety reason or something else?

Claire Zangerle: Well, I can tell you from a conceptual perspective and Erin can tell you from a lived experience perspective. So, from a conceptual perspective, registered nurses, we had to teach a lot of our registered nurses delegation skills. What do they give up to allow the LPN to do? And what can they trust the LPN to do within their scope of practice? So, delegation skills were very important conceptually to teach, along with the scope of practice, and teamwork and how to work together as a team. But in terms of lived experiences, I'm going to pitch that to Erin because she's the one who's really done most of this work. I'm just the one with the idea, she's the one who executed it.

Erin Todd: So, bringing on LPNs, the first barrier that we faced was what can they do? It was something that not too many people were familiar with working with them. And just as we, from a management perspective, are encouraging teamwork to our staff, I had to resource out to other managers within the network that have LPNs to figure out what can my new staff do? So, I worked with our emergency room, another local hospital that had some LPNs, to start getting scope of practice and where they were utilizing them and figuring out how we could implement that scope of practice into what works best on our unit. So, that was definitely the first barrier for us was like, we have these brand new sets of hands that we haven't had before. They can definitely do more than the nursing assistant, but working with an admission, or what can they do when a patient gets admitted to the hospital? There's certain things they can and can't do. What are they blood administration? Are they allowed to co- sign blood products? Because that's something that we have a double check for a lot of the things that we do. Where does that fall? And so those are things on the fly that our staff was wanting to delegate and wanting to work as a team, but we had to establish and really learn what they could do for us.

Claire Zangerle: I can tell you that a true non- negotiable, and Erin knows this because she lived this, was communication. You have to communicate with each of your team members because they work together as an orchestra. And if they're not communicating, if their instruments aren't playing together, then the patient's not going to get what they need. And there's going to be high frustration on the part of each of those team members. So, if you ask for one non- negotiable, that's it.

Erin Todd: 100%.

Paul Anderson: Erin, you mentioned an initial challenge of just figuring out what can these LPNs do as they come on to be part of the team? What are some other barriers that you ran into, whether you anticipated them or maybe some surprises that you got to experience along the way?

Erin Todd: Sure, yeah. Change in the nursing world, and it's probably everywhere else, is just a not good topic. Nobody likes change. So, when I go into a staffing meeting, I say," Hey, we're rolling out this new blended program. I'm so excited," the eyes roll, and it is, it's hard. So, you really have to be behind it. I really looked for my key players that I have certain staff members that are... they have my back, no matter what. And then what was really nice is I had a nurse that had just finished her bachelor's degree and had just done studies on blended nursing and was so excited because it's right out of school and she knew it. She's like," I just learned about this. This is so awesome." So, really having those cheerleaders helped. You really struggle with the ones that are like," Ah, we've done this before. We tried something like this." And so, really being positive and continuing to... Sometimes it's baby steps, it's starting with a really, really, really small changes. And that's where we found, we rolled out this big thing, and this is what we're going to do. We're dividing into teams and you're going to tackle these patients and you're going to handle these patients. And it was too much too fast. And so, we backpedaled a little and we really started with, okay, the first thing we're going to do is you as a team are going to establish when you're going to lunch, because that's evidence- based practice. When you get a break and you physically can walk off the floor, you come back refreshed and you deliver better patient care. And that's nursing. Everything we do is based off of evidence- based practice. Nursing is a practice, it's not black and white. So, we have to look to always in the research and that's something that's proven all the time that when you get that break, it makes a difference. We started there and I would notice because that's something that we track, is they have the opportunity to delegate or explain that they didn't get a lunch for their shift. I watched those start to dwindle down within my timekeeping that," Hey, everyone's going to lunch. This is nice." And then the staff started to catch on like," Hey, I went to lunch every day this week." So very, very small things. And that's really what started to unwind, is they had to buy in to what we were selling essentially.

Claire Zangerle: I'm sorry to interrupt Paul, but I'd say another barrier for us, beyond what Erin explained, which she explained it very well, and even some ways to combat those barriers, are compensation. LPNs make a lot of money outside of acute care and we were not competing with the hourly rate and we're still not 100% there. A lot of our LPNs come and say," You know what? I could work for an LTACH for a couple of bucks more an hour, but I want to be in acute care." Most of our post- acute care partners are for profit facilities. And sometimes an LPN is the highest level of clinician on a shift. So, of course they're going to pay them that. So, a barrier for us organizationally, was reviewing the compensation model for LPNs. And another barrier was the skepticism of LPNs actually believing that we were going to invite them back into acute care and make them part of the team. Because for so many years, that door had been closed. And once the word got out, that started to happen. And actually, we've even used our agency partners to help us identify LPNs who might want to come back into acute care, and not every region in the country has access to LPNs. Western Pennsylvania is blessed with a lot of LPN schools, so we are able to source those. This summer, we have 144 LPNs coming in to do clinical rotations in our hospitals. So, if we don't hire them, we are going to push them to our narrow network post- acute care partners to staff those, so that we can have a lower length of stay because our barrier to our length to stay is our post- acute partners not having staff. And if LPNs can help with that, then that's great.

Paul Anderson: Yeah. I mean, that connectedness of the whole system, that's a true health system.

Claire Zangerle: For sure.

Paul Anderson: That makes a lot sense, yeah. You mentioned Erin, noticing that people were all of a sudden, really consistently able to take lunch. That sounds like a really nice win that has a tie back to patient outcomes as well. What were some other wins that you were able to realize? Maybe especially ones that maybe you didn't expect?

Erin Todd: So really what I was not expecting, and Claire touched on it, having that assistant staff, the nursing assistants, the care technicians really took it inaudible patients and the staff work alongside each other.

Paul Anderson: Have you found as you've implemented this process, that there are some areas or units of a hospital that are more amenable to a blended approach versus others?

Erin Todd: So I actually, prior to taking this management role, I worked as the manager of hospital operations for three and a half years. And so, that's essentially the supervisor that walks around and makes sure that everyone's ducks are in a row. Professional fire putter outer is what I call myself. So, you handle the things, but then it always kicks back to that manager. So, I really have had the opportunity to see the differences in all the units and how they work. And really, what I love about this blended nursing and what I found is, it's not a one size fits all, it has to work this way approach, when once you take it in, you just really figure out how it works for your unit. So I really, really think that this could be beneficial everywhere. And that really going into it is understanding that it's not going to look the same. Five North is not going to perform the same as the intensive care unit, it's just not. But if you take those keys that... making sure people are getting breaks, making sure we're talking, making sure we're checking in with each other, it really will work anywhere.

Paul Anderson: Claire, earlier on you talked about the role and the impact of LPN staffing and having to do with Magnet designation. I wonder if you could expand a little bit on that and what is that role? What is impact? And are there concerns you had as you were developing this process with the increase in the numbers of LPNs and how that would affect the Magnet designation?

Claire Zangerle: Yeah. So, I wasn't so concerned about the introducing LPNs and it having an effect on our Magnet designation, whether were an already designated hospital, we were on the journey, or we were thinking about getting on the journey, and only because of this, because no matter the discipline that we have to help the nurse at the bedside, the evidence that we use to meet the standards of Magnet are still going to be met. And using any discipline that's going to help the nurse practice at their top of their license, that's going to help us. It's not going to take anything away from the value that we bring to the Magnet process. I know that that is a huge concern of many people, but if you get down to the brass tacks, you have somebody to help you do your work so that you can practice at the top of your license, which is always an element of Magnet designation.

Paul Anderson: One of the things that we've looked at a lot at ECRI and the ISMP patient safety organization over the last year or more now, is as we focus on reducing inequities and disparities in care, one of the topics that keeps coming up is making sure that we have a workforce that represents the communities we're serving in, that is representing all those same different groups in our community. I wonder if bringing back the LPNs into the acute care workforce, if that helps to make the workforce more diverse and more accurately reflect the community that you're serving in?

Claire Zangerle: Yeah, absolutely. What we've seen is that the cost of nursing school is sometimes prohibitive for anybody. And we're certainly seeing that in our marginalized populations, in our neighborhoods where people who would love to go to college won't have that opportunity, but this is a path, it's an entry level and LPN programs are affordable and they're funded with scholarships, and you can get federal loans, all kinds of things, much like you can nursing, but just the population that we're talking about, the diverse population, they are attracted to getting the degree or getting the licensure, and starting work and that's necessary. Yes, that is also, that's a collateral benefit for us to diversify our population of employees at AHN, because honestly, across the country, there's not enough diversity in healthcare. There's not enough diversity in physicians, in nurses, in any discipline of healthcare. And there must be that diversity because we all know from evidence, that outcomes are better if somebody who takes care of you, looks like you and understands your personal beliefs. And that is so important. And that's the hope for our collateral benefit of this program as well.

Paul Anderson: We've talked at a couple different points throughout the conversation about the importance of evidence and whether it's something about the evidence for the importance of a staff that looks like the patient population they're serving, whether it's the importance of taking that lunch break and coming back refreshed and able to really focus on the work at hand. I wonder if you've seen any evidence as you've moved to this staffing model, that really shows that it's having the impact you want it to have? Whether it's on safety outcomes, or employee satisfaction, or any of those measures that you might be looking at to say," Yeah, okay. We know this is doing what we wanted to do."

Erin Todd: Yeah, so actually we partner with Press Ganey as part of one of our surveys for our patients, to see how their experience is while they're in the hospital. And one of the areas where I've seen an increase on our unit is there's a question that asks do staff work together. And that's something that has really increased for us over the last six months. And you can see it. It's great data and it really, really is applicable to the blended nursing. It says," Did your staff work together?" That's pretty self explanatory there. So, that's definitely something that shows hey, people are taking notice that we're building each other up it's while we're working together, or one nurse is coming off and one's coming on, that they're still collectively working as a team and the patients are seeing that. So, from a patient perspective, we're seeing that. And then also from a staff perspective, we have a little... we call it a kudos board on our unit. And it's just that the nurses will leave shout outs to their team for helping them. And it's an idea I totally stole from somebody at a meeting that I said," I love that. That sounds great." And I put it up on our unit thinking," I don't know how this is going to do," and it just totally took off. And it's covered with thank yous," Thanks for helping with my assessment. Thanks for staying late with me. Thanks for doing my wound documentation." And it really shows that the staff is loving each other working together and it's just great to see.

Paul Anderson: I'm wondering, if you think about that kudos board, have you... My first question was going to be give me an example of some things that people are putting up there, but I guess, have you heard feedback from folks who have been thanked and they affirm that," Yeah, it's actually more meaningful than you might think to see my name up there and my colleague thanking me."

Erin Todd: Yeah, absolutely. And it comes from the people that you really wouldn't expect to say," Hey, that really made me feel good." I'll throw things up there sometimes. And last week was Nurses' Week. And I put a little blurb up there to say," I don't even want to say thank you because it's just not even enough to explain what they're doing for me and for each other." I recently took over this unit in end of December. And so, I was the assistant manager prior, and then I popped in and I was like," All right, we're doing all this stuff, guys. Sorry to drop it on you. But here it comes." And just having them take hold of it, and it's changed me, being able to really have a team. I'm really thankful to watch them work together like this and welcome me alongside of them.

Paul Anderson: One last thing I wanted to touch on before we wrap up is AHN's return to practice model. So, I wonder if you could describe a little bit about what that is, and also maybe give some examples of how you've seen that play out?

Claire Zangerle: Sure. We started this back in 2017, because what we were realizing is that we knew that there are nurses, there are nurses out there that kept their licenses up, but they weren't practicing. And they weren't practicing for a variety of reasons. We, in the hospitals, haven't been super flexible with schedules. It's like 12 hour shift, 10 hour shift, eight hour shift, or nothing. And people have life that they need to live. They might need to raise their kids and they might want to put their kids on the bus and then be there when they get home. They may have parents that they're shuffling to appointments, back and forth and things like that, that they can't work three twelves every week, or things like that. We needed to meet those nurses where they are, not fit in them into our little mold. So, we created this program called return to practice and we partnered with a company called iRelaunch. Initially, iRelaunch is a re- entry to work program for those exact types of people in other industries, in STEM, in banking and things like that, who have gone away from their career and wanted to come back into a career. And so we said," Let's do this for nursing." I'd done that at a previous organization where I was before. And I thought," I want to try this in Pittsburgh. I'm sure we can do it." And sure enough, we launched it. And we did a really soft launch because unlike where I was before in a different state, we had access to data that told us on their state nursing... The state board of nursing said," This is the group of nurses who are not working because on their license application, they check not working, but still licensed. And here's your pool of people." We didn't have that pool of people for Pennsylvania, but we just advertised about it. We talked about it. Our recruiters talked about it, word of mouth. The first year, we got about 60 nurses to come in to do that. Now, if you've been away from practice for five minutes, you need to get refreshed because every five minutes things change. So, we partnered with the University of Delaware because they had a very robust refresher course that people interested could do online. Self- paced, online and it assessed where they were. If they've been out five years, if they've been out 25 years, and we did have nurses that ranged from being out for a couple years, up to 25 years, want to come back. So, they'd take that refresher course and we'd pay for it. Upon completing that refresher course, we would pair them up with a preceptor on a unit of their choice, and they could go to that unit of their choice and work with that preceptor, and they got paid their hourly rate, which is a little bit less than our staff nurses because they didn't get benefits, or PTO, or anything like that at the beginning of the program. We've revisited that a little bit just because of the staffing shortages and because it's the right thing to do. So, they would partner and shadow with them. And then when they were ready to be independent, they were independent. And they had the flexibility of working a minimum of two hours up to a maximum of 12 hours in a shift. And there is not one time, 24/ 7, that we don't need a pair of hands. And if somebody wants to come in for two hours, we've got something for them to do. Mind you, this is a logistic nightmare for the nurse managers, but when they need those staff, they do it. I can tell you it, I think going forward, we're going to make this a harder push because I know that since the pandemic, people have left and do want to come back. So, Erin's got a lived experience where she's got return to practice nurses. And she probably has some of these experiences where it's worked and there's pros and cons of it, but we're leaning into the pros.

Erin Todd: Yeah, so we recently took on our first return to practice nurse and he had been out of practice for four years. So he actually took his boards, passed all that, had started to work, but then family life... was working for a family company. So, similar story, something outside pulls you away. So, he came back in and it was really nice because they start and almost like Claire said, it's almost like a clinical again. So, he was here eight hours a week over the course of, I think it was about 10 weeks, and then took his testing. Did really well through that and then comes back onto the unit to orient just like any other nurse. And what we had found was we were expecting because he was a return, to be ready to go, real simple orientation. And it just wasn't, that was a learning curve for us, is he had to start from the beginning and that's fine. We're used to that. It was just not something that we were thinking. But what he really liked about the unit was, shameless plug for the blended nurse, saying how welcoming and how well of a team we were. So, it was really good to see that. And from the beginning, him being able to come in here and not feeling like he was alone, or like a fish out of water, because we had this assumption that he would be able to do things. We really gave him all the support that he needed, but would let him fly when he was ready to.

Paul Anderson: So, I always like to wrap up these conversations by asking for one or two steps an organization can take to get started. So, if I'm in a health system and I've heard what you've said, and I'm ready to take that leap, but I know that I probably am not going to get an entirely new staffing model set up by the next pay period. Where do I start to move in that right direction?

Claire Zangerle: inaudible.

Erin Todd: Start with lunch breaks. Start with lunch breaks. It sounds so silly, but it's so important and it's something... It's an easy buy. It's," Look, the only thing I want you to do this week is go to lunch." That's an easy sell. Like," Okay, we can figure this out." And in order for you to go to lunch, it's not my charge nurse that's assigning six different people lunch because that's the way it used to work is," You're going at this time. You're going at this time." Because it doesn't work that way. Things change, patients get worse, or something unexpected happens. So just encourage," Okay, you three are working together today. Figure out how you're all going to go to lunch today." And it is very, very small, but it's something that they'll see and they'll like, and then they'll want to know more." Okay, what is this all about exactly, because now I'm fed and I'm happy. Now I want to listen."

Claire Zangerle: So, my piece of advice would be to engage your nurse leaders and your staff on what they think the solution is. Because what you may think is a solution from, I don't know, the nurse leader, or whatever, it may not be the right solution for that unit. And as a nurse leader, not one size fits all, modify it to fit you. As long as you have the common goal, how you get there from your unit. The nurse leaders are CEOs of their unit. How you get to that common goal is how you get to that common goal and make it interactive. Don't make it a top down, make it a bottom up, sideways in approach. And then I think you'll be successful.

Paul Anderson: Claire, Erin, thank you both so much for being with us today.

Claire Zangerle: Thank you.

Erin Todd: Thanks.

Paul Anderson: You can learn more about ECRI and the ISNP and PSO from the ECRI website at www. ecri. org, where you'll find our 2022 top 10 patient safety concerns report, which includes staffing shortages as the number one item on the list. You can learn more about Allegheny Health Network at www. ahn. org. Be sure to subscribe to Smart Healthcare safety on Spotify, iTunes, Google Play, or wherever you get your podcasts to get our latest episodes. We welcome your feedback. Please visit us at ecri. org or email us ecri- podcasts @ ecri. org.