2021 Look Back: Chief Nurses Get Creative in Tackling Staffing Shortages

From predictive algorithms to revisiting past care models to virtual nursing, nurse leaders are digging in and finding solutions to the current staffing crisis.

Nurse staffing created some of the most difficult trials for nurse leaders during 2021, but it also sparked their ingenuity as they searched for solutions.

As the pandemic continued its deadly spread across the United States, nursing shortages, which had been a challenge even before COVID-19 arrived, intensified. Nurses on the cusp of retirement opted to go, while others left because of burnout, contract labor opportunities, opposition to vaccination mandates, or to take care of family.

Indeed, nearly 30% of RNs are at risk of leaving their organization and millennial nurses are most likely to quit, according to a national analysis by Press Ganey.

In September, the American Nurses Association (ANA) asked the U.S. Department of Health and Human Services (HHS) to declare the current nurse staffing shortage a national crisis and take concrete action.

Crisis-level nurse staffing puts nurses' ability to care for patients in jeopardy, said the call-to-arms letter from ANA to HHS Secretary Xavier Becerra.

"ANA is deeply concerned that this severe shortage of nurses, especially in areas experiencing high numbers of COVID-19 cases, will have long-term repercussions for the profession, the entire healthcare delivery system, and ultimately, on the health of the nation," ANA President Ernest Grant, PhD, RN, FAAN, wrote in the letter.

Despite the dire conditions, nurse leaders at hospitals and health systems began getting creative and looking at alternative ways to safely staff their organizations.

Power of predictive analytics

Tower Health tackled the problem by taking a deep dive into staffing and workforce optimization using predictive algorithms.

"We wanted to use predictive analytics to help us staff-to-demand and reduce variations in staffing in situations we could predict and in unpredictable variation as well," says Mary Agnew, DNP, RN, NEA-BC, senior vice president and chief nursing officer (CNO) of Tower Health, based in West Reading, Pennsylvania.

The process began with exhaustive and painstaking data-gathering, for which Tower Health worked with management consulting company Kaufman Hall.

Tower Health began its work with Reading Hospital, the health system's flagship hospital, gathering data from payroll, staffing grids, the historical census—including the hourly census—for the previous three years for each individual unit, bed capacity, nonproductive time, turnover rate, vacancy rate, hours used for FMLA (Family and Medical Leave Act), nurse-to-patient ratio, and all other essential information to put into a workforce optimization engine, Agnew says.

"You really have to gather everything," she explains. "Your staffing is impacted by dozens of other variables other than hours per patient day."

The tool then created a model for each unit and identified what core staffing the hospital system would need to fulfill scheduling demands, Agnew says.

The next part of the equation was deciding what portion of their workforce would be flexible.

"You have your core workforce, which is lean, and then your flexible workforce, which is there for unpredicted variations," she says.

Predictive analytics provided a completely different way of scheduling, and when managers and directors saw how the new patterns improved staffing, Agnew says, they became believers.

The return of LPNs

Allegheny Health Network (AHN) is easing the nurse staffing crisis by welcoming back licensed practical nurses (LPNs) who were once shown the door by most U.S. health systems.

LPNs—alternately referred to as licensed vocational nurses (LVNs)—have been phased out over the last decade by health systems seeking higher-educated nurses who can provide a wider scope of duties.

Although 14% of LPNs remain in U.S. hospitals, many (38%) took their skills to nursing and residential care venues, according to the U.S. Bureau of Labor Statistics.

Claire Zangerle, DNP, MSN, MBA, RN, FAONL, NEA-BC, chief nurse executive for AHN, based in Pittsburgh, Pennsylvania, saw LPNs as a key puzzle piece in remedying nurse staffing and last summer began a pilot program placing LPNs on nursing teams.

The decision was met with some reluctance from her own teams.

"I said, 'Look, this is an option that we have. We can't get the nursing assistants, we can't get as many RNs as we'd like, but we have a group of people that we could reach out to,'" she recalls.

"We have LPN schools around our region, and we also have two nursing schools that we can matriculate LPNs into RNs if they want to," Zangerle says. "We have to give everybody the opportunity to do the work if they want to do the work and we have the structures in place to support that work."

AHN piloted the program in one or two large nursing units at each of its hospitals.

"We're doing pilot work with what used to be called team nursing but we're calling it blended nursing because we have an initiative throughout our enterprise called blended health between our provider organization and our payer organization," she says.

Patients are cared for by a blended team led by an RN and consisting of an LPN and a nursing assistant who divide up duties based on their skill sets, Zangerle says.

"A nurse can oversee more patients if the nurse has the support at the elbow that they need, and the LPN and the nursing assistant assigned as a team gives them that support," she says.

Zangerle sees the blended model as permanent for AHN.

"Objective and subjective data tells us it's working and it's a formula that's good for us. It's not on every unit, it won't work on every unit, and we don't need it on every unit," she says. "It's usually on the busy med surg units, it's good on rehab floors, it's good in orthopedics."

"All the data and predictions show us that it's not going to get better in the next decade, and we need to have alternative approaches," she says. "This is a highly viable alternative approach."

Virtual nursing solves more than just staffing problems

MercyOne Des Moines' innovative virtual nursing program uses videoconferencing technology and dedicated devices in each patient room, allowing the hospital's virtual nurses to assist bedside nurses by monitoring the unit from a remote digital center.

The model not only has helped ease the hospital's nurse staffing, but it has yielded so much more: improved quality; decreased falls; decreased medication duplication; decreased missed care; and zero catheter-associated urinary tract infections (CAUTI) rates, says Linda Goodwin, MSN, MBA, FACHE, senior vice president of clinical operations, integration, and innovation, who piloted the program in her former position as MercyOne's chief nursing executive (CNE).

The virtual nurse, who is responsible for 18 patients, participates in daily interdisciplinary rounds via teleconferencing, in which the patient's care team videoconferences into meetings, compares notes, and confers with each other, she says.

The virtual nurse, located in the virtual nursing digital center several miles away, then facilitates all care communications, such as calling for test or lab results, reviewing charts, handling discharge duties, and anything else the care team needs, Goodwin says.

Dietary, care management, and pharmacy also are part of the growing virtual nursing program, Goodwin says, adding, "It isn't just a nurse model anymore; it is a multidisciplinary model."

Busy floor nurses taking care of five or six patients particularly welcome the assistance and support virtual nurses provide because they see fewer falls and other harm because the virtual nurse has a constant eye on each patient; they can hand off discharge duties to virtual nurses; and they experience fewer interruptions, Goodwin says.

Goodwin credits the program's success to the forward thinking of Kathleen Sanford, DBA, RN, now executive vice president and chief nursing executive (CNO) of CommonSpirit Health, of which MercyOne is a part.

"Way back in 2011, Kathy made a prediction that the nursing shortage was not going to end, and we would have to adopt new innovative approaches to providing nursing care," Goodwin says.

The virtual model has become so favored at MercyOne that more nurses are requesting it, Goodwin says.

"The only limiting factor is getting virtual nurses hired," she says, "and then being able to spread it as quickly as we want."