Why It Matters
Recently reported data confirms the fears of many in the patient safety community about the impact of the COVID-19 pandemic: significant increases in healthcare-associated infections, declines in staff ratings of safety culture, and upsurges in some nurse-sensitive indicators (including patient falls and pressure injuries). The shortage of available staff, including nurses, has increased throughout the pandemic. Many organizations are dealing with the challenges that come with a growing proportion of their workforce being temporary staff. Given the association of nurse engagement with patient and workforce experience and outcomes, meaningful engagement of all nurses, both permanent and temporary, is a critical leadership priority.
The use of temporary nurse staffing predates the COVID-19 pandemic by several decades. Generally, it has been driven by the desire to use a flexible workforce to reduce labor costs, the need to address labor shortages related to variations in patient volume, and other market forces that impact the supply and demand of nurses. In recent decades, the number of health care organizations using temporary nurses has increased and surged to record levels during the current pandemic.
Temporary nurses are commonly sourced from external travel agencies or an organization’s per diem or float pools. Health care systems are increasingly turning to the creation of internal agencies as a solution to reduce dependency on external agencies and to attract and retain temporary nurses within their system.
Given the massive shifts in workforce trends within and beyond health care, leaders must unify and engage both temporary and core staff in optimally serving patients, families, and one another. What we’ve learned from decades of experience is that safety is a systems property and requires organizations and leaders fully committed to the safety and well-being of patients and the workforce. Central to this work are cultures of safety and healthy work environments in which individuals and teams are psychologically safe and can perform, professionally thrive, and provide the best care possible. While evidence suggests that more nursing staff is associated with improved outcomes, simply employing more staff (whether permanent or temporary) is not sufficient to ensure patient and workforce safety.
At a time when many organizations rely on temporary staff to fill the gaps left by staffing shortages and problems with workforce retention, is it possible to create the conditions for the team performance necessary for patient and workforce safety? After all, high-performing teams generally take time to develop, especially in terms of building trust and psychological safety. Frequent personnel changes for nursing, nursing support, and other health care roles can be disruptive to team building, communication, and cohesion. Organizations that use temporary staff — and agencies that provide temporary staff — must be mindful of the risks associated with large and sudden shifts in a “blended” workforce and should continuously monitor and calibrate the oversight of such changes. They must be keenly focused on fostering and sustaining a culture of safety, with shared goals, clear roles and expectations, timely and transparent communications, continuous learning and improvement, a shared understanding of policies and procedures, and consistent standards of accountability.
Keys to Promoting More Engaged Blended Staff Environments
A strong safety culture is highly associated with engagement from both permanent and temporary staff. Fostering safety cultures and safe work environments enables all team members to provide the best care and is foundationally vital for attracting and retaining a stable workforce and achieving high team performance. Here are some keys to creating a safety culture for all:
- Leaders must fully commit to patient and workforce safety. Leaders and organizations must reinvigorate their dedication to safety as a core value, and re-commit to fostering and improving cultures of safety. Some tools that leaders can use to assess and anchor this work include Safer Together: A National Action Plan to Advance Patient Safety, Leading a Culture of Safety: A Blueprint for Success, and the IHI Psychology of Change Framework to support adaptation and advance sustainable improvement.
- Assess your current state and anchor your focus on the foundations. To foster optimal team performance, leaders must understand the gaps and opportunities for focus at the organizational, unit, and department levels. Many factors that impact attraction and retention of the nursing workforce are integral to engaging teams. What do your culture of patient and workforce safety, healthy work environment, and staff engagement surveys tell you? What do your patient and workforce safety outcomes (including nurse-sensitive quality indicators) reveal? How are you capturing the feedback and experience of both permanent and temporary staff? Create a plan, informed by your nurses, that addresses the conditions and experiences of permanent and temporary staff. Focus on ensuring safety, well-being, and team performance.
- Listen to staff and reinvigorate shared governance initiatives, including unit- and organization-based councils that focus on orientation, onboarding, and support for permanent and temporary staff. Leaders have an important role to play in listening for and eliciting feedback from all staff to advance shared learning of clinical and professional practice challenges, and in managing conflicts when disruptive, unprofessional, and unsupportive behaviors emerge. Some staffing challenges can be prevented by listening to and addressing the concerns of the current workforce to create a culture and environment that encourages retention and attracts new staff, including temporary nurses who may decide to remain permanently within an organization. Permanent staff can be engaged in staffing discussions to clearly identify the necessary skills and competencies to address patient needs and codesign solutions to support both permanent and temporary staff during transitions. Topics can include improvements to onboarding programs, communications about expectations and performance feedback (for both permanent and temporary staff), and the use of buddy system assignments.
- Support continuity of care and balanced staffing assignments. Frequent care transitions can increase the risk for patients, so supporting continuity of patient assignments whenever appropriate is advisable. Maintaining balanced and appropriate workloads and allowing for rest and recovery is important for all staff, especially given burgeoning rates of workforce fatigue and burnout.
- Encourage open communication. Frequent huddles at the beginning and throughout shifts provide opportunities to engage all staff in proactively speaking up to identify safety risks and solutions for protecting both patients and the workforce. They can also build comradery.
- Recognize the risks of — and aim to address — compensation disparities. While there is no doubt that financial incentives can be attractive to fulfill short-term staffing needs, imbalances in compensation can lead to discontent and resentment. The resulting negativity and cynicism can undermine cultures of safety and team performance and lead to increased turnover.
- Support all staff and address short-term and long-term workforce solutions. Leaders set the tone as organizations respond, adapt, and support all nurses in the face of challenging staffing realities in both daily work and longer-term planning. Putting nurses and the patients we care for at the epicenter of designing and implementing staffing and care delivery solutions is vital at national, organizational, and unit levels. Follow the evidence, recommendations, and resources of the national Partners for Nurse Staffing initiative, of which IHI is a member.
There is little doubt that a blend of both temporary and core staff will be a reality of the nursing workforce for the foreseeable future. Organizations and leaders have multiple opportunities to tap into the invaluable experience and insights of all their nurses to develop a cohesive culture of safety and support optimal team performance. It is in the best interests of patients, families, and all health care professionals to acknowledge and address the challenges and opportunities of an evolving health care workforce.
Patricia A. McGaffigan, RN, MS, CPPS, is an Institute for Healthcare Improvement Vice President and President, Certification Board for Professionals in Patient Safety.