The Exec: Are Your Nurses Dissatisfied? Then Change Things Up

Flexible scheduling and new care models can help provide nurses the work-life balance they demand.

Getting creative with staffing and offering flexible scheduling to nurses are among the strategies that acute-care hospitals can adopt to keep the nurses they have and attract new ones, says a health system executive.

"The nursing exodus is driven, in part, by a desire for better work-life balance," says Jill Bayless, MSN, APRN, FNP-BC, NEA-BC, FACHE, HACP, senior vice president of clinical services for Community Hospital Corporation (CHC), based in Plano, Texas.

"Double shifts, erratic and inconsistent scheduling, and menial tasks are contributing factors that have led to a sense of imbalance and job dissatisfaction among nurses,” Bayless says. “This situation has worsened mainly due to COVID-19's ongoing impact on healthcare workers."

Bayless spoke with HealthLeaders about how flexible scheduling and new care models can help solve those contributing factors.

This transcript has been lightly edited for brevity and clarity.

HealthLeaders: What care models are being adopted to help with nurse retention?

Jill Bayless: Healthcare has eased into mostly an RN-driven staff model in hospitals and as COVID drove a lot of nurses out of hospitals, many retired, and a lot of them went traveling. It made hospitals look at different ways to take care of patients.

Hospitals within our systems are doing different models. One of them is what we call the dyad model, where you have a care team of an RN and certified nurse's aide or a PCT [patient care technician]—someone who is not licensed—working together. We’re using those models right now in some of our long-term acute-care facilities.

At our acute-care hospitals, we had to start looking at how we could still take good care of all these patients without having the RNs we had in the past. We call that the triad model. Some people who are senior careerists like myself used to call that the team model, which can be a variety of mixtures of staff. Generally, it is an experienced RN, and then inexperienced RNs or LPNs or LVNs—depending on what state you are in they are called different things—and then a PCT or certified nurse’s aide.

Some of our facilities were doing this before COVID because they couldn’t get enough RNs in their rural communities, but a lot of our larger hospitals that had shifted to all-RN staffing are, as they have an RN vacancy, asking, “Do we really need an RN for that? Can we use a very green, brand-new RN or could we use a seasoned LPN?”

Others are adding a respiratory therapist to that team so there’s a team of three people—two RNs and a respiratory therapist—taking care of sick patients. A lot of ICU patients are ventilated and require skills related to mechanical ventilation or CPAP machines and a respiratory therapist can do that. Respiratory therapy personnel are also very experienced in dealing one-on-one with patients.

HL: How do these care models benefit nurses?

Bayless: They know they are supported by someone who has more experience than they do. During COVID, brand-new RNs were coming out of school with very little hands-on experience and being put in situations where maybe they had the didactic knowledge, but none of the practical experience, so this model allows for those new RNs to learn under someone who is very seasoned and experienced.

That also allows for that charge RN to not be doing what I'm going to call mundane tasks—that doesn’t mean they aren’t important, but they’re things like doing blood sugar, taking linens, and helping patients to the bathroom. A certified nurse's aide or a PCT can do that.

It does involve the charge RN going around and meeting every patient at least twice a shift and then more often if they have something more critical going on, so they would still be assisting that LPN or new grad RN and assessing that patient and helping them understand the care needs or whatever that diagnosis is.

HL: When nurse leaders are considering changes, how should they best effectively adopt a new care model into their organization?

Bayliss: I don't know that this is the best way, but I can tell you how we are doing it here. We've engaged all of our CNOs, and our focus is to have a triad model or a dyad model, depending on what kind of hospital they are.

It really has to be driven by the CNO at the local level, along with the director of the unit where that change is being implemented, and you have to get input from your staff on that. The director of the unit and the CNO will talk about anticipated changes with their unit and listen to staff and hear their ideas about how it could work best there.

There’s no one-size-fits-all, and there never is in healthcare. Staffing, size of the unit, makeup of the unit, experience of the staff on all levels—all that has to be taken into consideration.

HL: How can flexible staffing create a more satisfied and engaged workforce?

Bayliss: Generally, what we see now is that staff are scheduled three 12-hour shifts, so for a single mother who has a daycare that’s open only 10 hours a day, they can't work those 12-hour shifts, or they have to find some interim solution that will allow for that child to be cared for in the hours outside of that daycare’s opening. Some facilities are looking at whether they can offer eight-hour shifts in addition to three 12-hour shifts to staff, and then someone to work all weekends, which is an old model, called the Baylor Model.

Other ways are hiring tele-nurses to help with things like admissions and discharges and medication reconciliation, all of which are time-consuming for the nurse on the unit. Nurses who can't do long shifts can work within a tele-nursing position.

I implemented “mother’s hours” some years ago to fill voids during the busiest time of day. We had busy times from about nine in the morning until about 2:30 in the afternoon and a lot of mothers with children in school were able to fill those positions because they could come in after they got their child on the school bus or dropped them off at school, and then they got off in time to be at home or to pick that child up.

Some facilities are doing a seasonal nurse schedule. Typically, in ICUs and intermediate care units, their busiest times of the year are September or October through about April or May. Based on the volumes of the unit, some facilities are offering seasonal work schedules where nurses could work about nine months, get full benefits, get full pay, but then be off in the summertime or whatever months are not as busy for those units. It still gives the staff that flexibility of having them when the volumes are hot, but not having them when they're not needed.

Those are all ideas, but what works in one market may not work in another market. You have to look at things that give some relief to that staff on the unit.