Our organization utilizes a budget-based approach that incorporates patient:nurse ratio with informal assessments of patient acuity. Shift-to-shift staffing flexibility is supported by a centralized resource team. The organizational risk created by units’ non-standardized use of on call, call back and floating practices prompted an evidence review for ways to supplement our conventional staffing model, was but little was found. One report about a voluntary program (Good & Bishop, 2011) helped springboard the development of an additional layer of flexible staffing. Our new program, called Happy to Help (H2H) used budget-neutral structures and processes to incentivize existing staff to work additional shifts at premium pay. In addition to standardizing practice, the H2H staffing program aim was to improve nurse perception of adequate staffing (NPAS) without negatively impacting nurse sensitive quality indicators (NSQIs), nurse turnover, or cost.
Before going live with H2H staffing, campaigns to improve the culture of floating were launched about appropriate reallocation and to “put out your best linens” for floating nurses . Using a template, every unit created a one-page resource sheet that described basic unit resources and routines on the front. The back contained a 9-item questionnaire about the floating experience. The resource sheet was given to all nurses who floated and surveys about the experience were collected for follow up.
In October 2017, the H2H staffing program was implemented across 3 hospitals on inpatient units except those in Surgery, Imaging, and Women’s/Children’s services where expertise was deemed uniquely specialized. The revised staffing policy discontinued unit-based on call and call back. Nurses in good standing were invited to register for the H2H program and then sign up for 4-, 8-, and 12-hour H2H shifts of their choice. ShiftWizard© scheduling software (Morrisville, NC) was used to identify and track H2H shifts. At the beginning of a shift, H2H volunteers were contacted by the centralized staffing office to fill an organizational need or if not needed, they were released from the shift. If needed to work, nurses were paid an H2H differential in additional to any other pay differentials the work might qualify for. Happy to Help nurse assignments were based on expertise, experience, and lastly preference. Volunteers were not assigned H2H shifts on their own units.
Process evaluation included monthly H2H enrollment number, utilization rate, cross campus floating frequency, culture of floating survey pre-post comparison, nurse turnover rate, and program costs. The outcome, pre-post NPAS, was evaluated using a survey since only staff nurses can confirm if staffing structures are working effectively and efficiently (Kramer & Schmalenberg, 2008). The NPAS survey was developed using concepts from the literature (AACN, n.d.; Huddleston, Mancini, & Gray, 2017; Pejtersen, Kristensen, Borg, & Bjorner, 2010) and included 15 NPAS items rated on 7-point Likert scales. The 3-month post survey contained an additional 6 items specifically about H2H and areas for comments. Data analysis included statistical process control charts and conventional rules (Institute for Healthcare Improvement, n.d.) for monthly NSQIs from 1 year pre- to 7 months post-H2H implementation. Cumulative yearly costs were compared for on call, call back, shift bonuses, and overtime pay for all direct care nurses filling shift-to-shift reallocation needs in H2H areas. Survey data were analyzed using descriptive statistics, bivariate analysis, and qualitative thematic analysis.
Results showed that H2H monthly enrollment rose from 92 nurses at outset to 272 nurses currently. After 3 months, the proportion of H2H shifts worked compared to those signed up for had stabilized around 70-80%. On average, 5 (SD 3.3) H2H nurses floated each month to a campus other than their own. Every effort was made to assign H2H volunteers to their home campuses; however, anecdotally, off campus floating was a satisfier to some H2H nurses who live closer to the hospital they prefer to float to. After implementing H2H, resource nurses (N=127) rated 5 of 9 survey items about the culture of floating improved: meal break offered, assigned a supportive buddy, felt like part of a team, care focused on excellence, and would like to be assigned here again. The NSQIs (i.e., falls, falls with injury, CAUTI, mortality) and nurse turnover rate showed no out of control process variation despite influenza season. In 2016 when focus began on appropriate reallocation followed by a “welcoming culture of floating,” costs decreased 4%, then 13% in 2017 and in 2018 after 7 months of H2H, annualized cost savings decreased another 46%. Total savings in flexibile staffing (i.e., on call, call back, bonus pay, H2H, and overtime) for the 3 years was over $1.5 million.
Pre-post response rates on the NPAS survey were 32% (717/2255) and 12% (284/2276), respectively. Although no difference by age, shift, campus, years in nursing, years in current position, or position type, relatively more nurses reported being a charge nurse post (40% pre vs. 55% post). Post respondents also reported less floating (94% pre vs. 30% post) and fewer hours working (M 34 pre vs. 25 post). Fourteen of 15 NPAS items were improved (all p <.001). Staffing practices were perceived as more voluntary, supportive, appropriately incentivized, fair and equitable, consistent, supportive of work-life balance, ensuring the right resources regardless of location, and beneficial to nurses, patients and the organization. Staffing was also perceived as less stressful, less demanding on nursing leadership, and increasing job satisfaction and assurances that staffing was meeting productivity targets. Perception about matching skills and experience to assignments, which received the highest score on the Pre survey, was the only item that although improved, had not changed significantly.
In our conventional staffing model, the H2H program incentivized voluntary floating for existing staff, provided an additional layer of flexible staffing for most service lines that aligned patient needs with professional variation, resulted in substantial cost savings without negatively impacting turnover or NSQI, and strengthened one component of a HWE. Although NPAS improved, it is possible that the strategies implemented to transform the culture of floating may have led to better collaboration, communication, or authentic leadership over time, thereby improving satisfaction and retention (Ulrich, Lavandero, Woods, & Early, 2014). However, we do not believe that strategies implemented in the 2 year period prior to H2H explain the large improvement in NPAS observed after only 3 months of H2H. After H2H implementation, nurses also reported floating less often and working fewer hours. We attribute these findings to better reallocation of resources necessitating fewer unique nurses needing to float and our observation that some nurses prefer to float for additional income while most prefer to be released from expectations of mandatory on call and overtime resulting in less time worked. While NPAS improved, suggesting that adequate staffing was achieved, we do not yet know how many nurses are needed in the H2H staffing pool for optimal flexibility in meeting organizational needs. We continue to encourage staff registration and hold units accountable to a welcoming culture for floating nurses. After 6 months, cost savings were invested back into the program by increasing the H2H pay incentive an additional $4.00/hour which resulted in additional program enrollees. Findings are not generalizable and ongoing evaluation is needed. Lessons learned include appreciation of the importance of actually working staff on the H2H shifts they have volunteered for, sensitivity addressing the ownership some units have for covering their own needs, consideration of preferences in floating location, the handling of overtime for H2H participants, and the need for additional education to address misconceptions about the program.