To offset nurse burnout, one health system gets creative

By Eileen Schreiber Radis, principal, Deloitte Consulting LLP

Nursing can be physically demanding and emotionally draining. Many nurses report feeling stressed, frustrated, exhausted, and unsupported.¹ While burnout has long been a part of the profession, it was amplified by the pandemic.² Creating a more flexible staffing model, reducing low-value and administrative tasks, and helping nurses advance their careers could help reduce burnout while also improving retention, according to Deloitte’s survey of 500 frontline clinicians (see Addressing health care's talent emergency). However, most of our respondents said their organizations could do more to address burnout.

Claire Zangerle is chief nurse executive at Allegheny Health Network (AHN)—a 14-hospital system based in Pennsylvania. She was recently named to Modern Healthcare’s 2023 class of Top Women Leaders in Healthcare. Claire is also a board member and co-chair of the Workforce Committee of the American Organization for Nursing Leadership (AONL), a subsidiary of the American Hospital Association. About 18 months ago, AONL formed a committee to develop strategies to address the health care staffing crisis, particularly among staff nurses and nurse leaders. Deloitte facilitated virtual focus groups with AONL members—and the extended nurse leader community—on retention and burnout.

I recently had an opportunity to chat with Claire about workforce challenges and find out what her organization is doing to address them. Here is an excerpt from that conversation:

Eileen: Nurse burnout and clinical staff shortages are not new for hospitals. But COVID-19 seems to have exacerbated those challenges.

Claire: That’s right. We faced workforce shortages long before COVID-19. The Affordable Care Act, for example, expanded health coverage, which is important. But the law did not consider whether health care organizations had enough staff to take care of the newly insured. Many of these new patients had not seen a care provider in years and some were dealing with multiple chronic illnesses. I feel like by the time we caught our breath, the pandemic hit, which intensified staffing issues, and many nurses retired or took non-direct care positions. 

Eileen: It seems that the work model for nursing may need to shift to meet the moment, especially given changing expectations of the current nursing workforce. During focus groups, nurse leaders noted that the profession often demands 24/7 accountability. At the same time, many nurse leaders and front-line nurses are asking for increased flexibility. What is your organization doing to make their jobs more flexible?

Claire: Some of our nurses left us because the schedule was too rigid. Many of them have kids or adult parents they are caring for and they needed flexibility. We created the RetuRN to Practice program, which allows nurses who left nursing to return to AHN on their terms. If a nurse can only work two hours a day, we can put them to work. The logistics are challenging, but my nurse leaders don’t mind because they have holes in shifts that they need to fill. It also means the nurse managers can manage their teams rather than filling in themselves, leaving them time to lead. The program also helps to supplement new nurses who might have received their clinical skills training virtually during the pandemic and have limited bedside experience. It is like an on-the-ground apprenticeship. However, someone who has been out of nursing for five years can’t just jump back in. We require them to complete an online refresher course through the University of Delaware, which we pay for and pay them to complete.

Eileen: Hospitals and health systems often use travel nurses to fill critical gaps, which can cost several times more than a staff nurse [see Why are nurses leaving…and what can hospitals do?]. What has been AHN’s experience around agency travel nurses and are you doing anything differently?

Claire: Prior to the pandemic, we had fewer than 100 agency travel nurses across our health system. Today, I have more than 700. Many of our staff nurses left to become travel nurses. In response, we created an Internal Staffing Team, which is similar to a substitute-teacher model. The nurses are on short-term assignments wherever they are needed. We place them in assignments by looking at our volumes across the network and identifying holes in the schedule that need to be filled. We can’t offer them the same pay as an agency, but we are able to pay them our crisis rate, which is $20 an hour more than the regular hourly rate. In addition, if a nurse has to travel more than 50 miles, we pay for their mileage. If even further, for example at our Erie, Pennsylvania or Western New York hospital, we will put them up in a hotel, if needed. Last September, we set a goal of attracting 100 nurses through this program. We reached that goal in just three weeks, and now have 175 nurses in the program. As AHN employees, these nurses get health coverage, tuition reimbursement, professional development, and other benefits that they won’t get from an agency. In return, they give us the flexibility of meeting staffing needs where we have them.

Eileen: What are you doing to reduce low-value administrative and operational tasks that nurses have to complete?

Claire: Administrative and operational tasks, like stocking shelves and making phone calls, can take time away from patient care/nursing practice, and ultimately, take the joy out of nursing. We want our nurses to find joy in their work. We encourage our nurses to challenge why things are done a certain way if it doesn’t add value or improve care. Nurses are excellent at figuring out workarounds. But if they have to use workarounds, the original process probably needs to change. The Joint Commission recently eliminated 168 redundant standards.³ That's the exact same thing that we are trying to do internally. For example, we are trying to reduce the number of clicks required to finish a task in the [electronic medical record] EMR. Another time waster is requiring nurses to stand in the nurse's station and wait for the doctor to call back. Nurses can’t use their personal devices to communicate with a doctor because of protected patient information. We have switched to a unified communication device that allows nurses to communicate with doctors on a secure device.

Eileen: Can we talk a little bit about recruitment? I imagine it has gotten much more challenging.

Claire: The pond we're fishing in has a lot less fish than it used to. Right now, I have 1,100 openings for staff nurses. Our recruitment team recently told us their goal for 2023 is to hire 600 nurses because they know that is what may be available in our region. Clearly, that’s not enough to meet our needs. Nursing schools are not graduating as many students as in the past because they often don’t have enough instructors. As a result, they sometimes must turn qualified applicants away. In addition, nursing school is expensive. We have two tuition-free diploma nursing school programs at Allegheny Health Network, but our capacity is only about 120 graduates a year. We have created hybrid positions where nurses can work part-time at the bedside, and part-time as a nursing instructor. A lot of our nurses like this option because they can advance their career without leaving the bedside.

Eileen: Once you have recruited a nurse, what do you do to help make sure they stay? 

Claire: The number-one factor is compensation. We recently made a $92 million investment in our compensation and benefits, across the network, with the majority of that being designated for direct care nurses, which includes a higher hourly rate and new benefits like parental leave. We have also accelerated merit raises by six months and created more robust clinical ladders for them. If nurses meet certain milestones, we increase their hourly rate by a dollar or two. We also give them professional-development opportunities. It means more work, but it also means higher compensation. We also offer higher pay for nurses who work nights or weekends.

Eileen: Virtual nursing seems to be emerging as a potential solution to staff shortages. Has AHN considered virtual nursing?

Claire: Virtual nursing today is super inviting and there are quite a few vendors that offer it as a solution. We don't yet know the true value of virtual nursing for us, but we are trying it. We have been experimenting with having a virtual nurse on an iPad—we call it “nurse on a stick”—who can spend more time with a patient than a nurse on the floor who might be running up and down the hall responding to call lights from three or four rooms.

Eileen: Through the nurse-leader focus groups, we found that nurses who experience higher burnout are less likely to voice their concerns. They often don’t think they will be heard. That could be an important call to action. How do you engage with your nurses?

Claire: Every time we conduct an employee-engagement survey, we are a little afraid of what we are going to learn. If you ask, you must listen and be willing to make changes. But we are committed to asking and listening. At AHN, we conduct an annual clinician wellness survey. Between 2021 and 2022, our nurse burnout rate fell by 13%, and burnout among nurse leaders shrunk by 9%. That is because we listened to employees and made changes. For example, one issue was to improve safety. We learned that some of our parking lots were not well lit. A nurse who leaves a shift at 11pm might not feel safe walking to their car. We have since added more lighting. We also learned that some nurses might work a 12-hour shift without a meal break. We recognized the problem and are now more intentional to build break times into schedules. Those little things really do matter, and it shows the power of listening.

Conclusion

When we care for our nurses and other front-line clinicians, we contribute to the hospital’s mission of delivering high-quality care to the communities they serve. Health care organizations can start by listening to their nurses and by  tapping into their own clinical staff as a source of innovation and inspiration.

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Endnotes:

¹ Burnout in United States healthcare professionals,  Cureus, National Library of Medicine, December 4, 2018

² Annual Assessment Survey, American Nurses Foundation, January 24, 2023

³ Joint Commission announces major standards reduction, The Joint Commission, 2023

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