Travel Programs, Flexible Work Options Shore Up Retention, Recruitment

By Dorothy Brooks

A nursing shortage has left many medical facilities scrambling to nurture new talent pipelines as veteran nurses are lured away by more lucrative travel positions or elect to leave the profession entirely.

As veteran nurses leave, those who remain are left to pick up the slack, which causes more fatigue and burnout. Complicating matters further, many administrators are navigating through tough fiscal waters. Thus, as leaders desperately seek to recruit fresh nursing talent, they are laying off personnel in other areas just to get by.

With all these factors at play, what can leaders do? Some healthcare systems are giving their nurses new opportunities to enhance their compensation while also providing supervisors with a new source of manpower to fill nursing holes.

In January, Rudy Jackson, DNP, MHA, RN, CENP, senior vice president and chief nurse executive at UW Health based in Madison, WI, was not sure how he could stop the nursing exodus. The rate at which nurses were leaving was unsustainable for the organization. Jackson realized he had to solve the problem or eliminate beds. That is when a nurse in the organization called Jackson with the germ of an idea.

“She wanted me to convince her not to become a traveler,” Jackson recalls.

The newly married nurse indicated she wanted to accelerate the couple’s mortgage payments, pay off her student loans, and purchase a new car; becoming a traveling nurse could help her with all this. At the time, Jackson acknowledged the nurse probably was right, and said he was not sure he could convince her not to leave.

However, the conversation jumpstarted Jackson’s thought process about a potential solution that could convince this nurse to stay and stabilize the organization’s nursing workforce.

Jackson huddled with other nurse leaders and quickly came up with a proposal for what they referred to at the time as an internal travel program, a way for in-house nurses to make more money by signing up for extra shifts where they are needed.

Nursing leaders met with the organization’s workforce management team and senior executive leaders to secure permission to move forward. Once leadership gave the green light, the organization implemented the approach in a matter of days. “If nurses picked up an additional 12-hour shift per week, that shift would be paid at their hourly rate, plus whatever other incentives [go along with the shift such as] if it is a night shift or a weekend shift, and we were going to add an additional $100 per hour to that rate of pay,” Jackson shares.

Nurses signing up for the plan would be committing to work the extra shift for six weeks, since UW Health operates with a six-week scheduling plan.

The plan was an immediate success, with a total of 600 nurses signing up for the program during the first six-week scheduling period. “This still cost us less money than the external travelers were charging at the time, and we were able to fill roughly 90% of our holes within the organization,” Jackson reports.

Notably, nurses could sign up only for roles they were competent to fill. For example, emergency nurses would sign up for roles in an ED. ICU nurses would be matched with ICU shifts.

“We worked with our department of education here within the system to develop a competency document that had to be maintained,” Jackson explains. Nurses completed this document, and their supervisors signed off if the employee could fill the role.

Jackson adds the goal was to avoid bringing any nurse onto a floor who the health system had to orient. The focus was on matching nurses with shifts where they could immediately take on a full patient assignment.

While the nursing staff largely approved of the approach, they were interested in some changes. For example, some requested cutting the commitment from six weeks to four. Certain nurses reported feeling overly fatigued after working an extra 12-hour shift for six weeks.

The program has continued to evolve. Leaders changed the way the nursing vacancy rate is defined, and then established a corresponding incentive pay structure based on that rate.

“The human resources [HR] department has a very traditional vacancy rate definition. If I’ve got 10 nursing positions and five are open, I have a 50% vacancy rate. Then, if HR does its job and recruits five people, the vacancy rate is zero,” Jackson says. “But from a nursing perspective, just because I have a body in the building doesn’t mean [that person] is capable of taking a full patient assignment, so we created a definition within nursing that we refer to as the functional vacancy rate.”

The new definition gives leaders the ability to determine how many nurses are on staff who can take a full patient assignment. “It takes into account nurses who are being precepted, nurses who are out on parental leave or medical leave, and then we are allowed to make adjustments to our base staffing plan based on that information,” Jackson says.

Today, if the functional vacancy rate for a unit is between 0% and 6%, that is the normal staffing model. If the functional vacancy rate is between 6% and 12.9%, UW Health provides a $50-per-hour incentive to work in the unit. If the functional vacancy rate is between 13% and 18.9%, leaders provide a $75-per-hour incentive to work in the unit. If the functional vacancy rate is 19% and above, there is a $100-per-hour incentive to work in the unit.

The program is operational at three of UW Health’s acute care hospitals in the Madison region, with administrators looking to apply the approach elsewhere. UW Health is working on a similar staffing program for the health system’s clinical research unit (CRU), a division where nurses work on high-level research programs and projects that are conducted by academic partners. “This area is so highly specialized that you can’t necessarily pull a nurse from another unit and put them in this unit, so we are creating a program specifically for the CRU with all the same benefits that the other units have gotten within the hospitals,” Jackson says. “We are also looking at other areas in nursing so we can support the entire system.”

Jackson admits before the plan was implemented, he was concerned about how their colleagues would perceive nurses signing up for extra shifts. “When I was at the bedside as a nurse, travel nurses who came into the organization and made more money ... were not always seen in the best light,” he recalls. “Often times, that caused some friction between the [in-house] nurses and the external travelers. I was afraid that with this program, we might see some of that within our own workforce.”

However, such fears were unfounded, as the nurses have been supportive and appreciative of colleagues who are picking up shifts because they are UW Health nurses. “We aren’t bringing in someone from a different state who is going to make a whole bunch of money and then leave,” Jackson says. “These are individuals who are already invested in our community, and already invested in our patient population, and very passionate about our mission and our culture at UW Health.”

Even nurses who cannot participate in the incentive program have embraced their colleagues who are picking up extra shifts.

“[Many] are glad the program exists because when they come into work, they know they are going to be working side by side with their colleagues,” Jackson notes. “That has been a real game-changer for the morale on the units.”

Jackson adds even some nurses who left UW Health for lucrative travel opportunities have returned. “We have also seen some external travelers decide to relocate and take full-time positions at UW Health,” Jackson reports. “We’ve seen an uptick in the number of experienced nurses who are picking up positions here within our organization.”

Philadelphia-based Jefferson Health also has developed an internal float team, a dedicated group of nurses who are deployed routinely to the areas of greatest need. This “Nursing SEAL Team” develops flexible workforce options, according to Andrew Thum, MSN, RN, director of nursing workforce operations at Jefferson Health.

“It gives the staff nurse the option to kind of craft where he or she works ... but it is also flexible from a nursing workforce management perspective in that the organization is able to align staffing resources where they are needed most,” Thum explains.

The Nursing SEAL Team is its own core unit. The nurses self-schedule where they will work in six-week increments.

“Then, 24 hours before the start of their shifts, they receive confirmation of which hospital campus they will be deployed to. Two hours before the start of their shift, they receive confirmation of which unit within that hospital campus they will be working at,” Thum says.

Compensation is based on how many hospitals these nurses are willing and competent to work in across the health system. There are three tiers of compensation. Tier one includes nurses providing the least flexibility in terms of which hospitals to which they are willing and able to be deployed. Nurses in tier three are willing and able to be deployed to any hospital in the health system.

“There are something like 100 different medical-surgical units that [tier 3] nurses will work at. This definitely requires a lot more in terms of commitment and skill, in some ways,” Thum says. “Therefore, we do recognize that and reflect that in the characteristics of the team members who we recruit for a more competitive compensation package.”

When the program launched in May, nurses were deployed to areas of need as they completed a program orientation. The results achieved thus far have been positive.

“When we look at the number of staffing requests or needs across our divisions on a weekly basis, since implementation of the SEAL Team we have been filling anywhere from 12% to 15% of those predicted needs for the following week through this team,” Thum reports.

While that might not sound like a lot, Thum notes that before the team’s implementation, those needs either went unmet or they were filled with core staff overtime, core staff incentive pay, or through agency.

“Through the implementation of this program, we are increasing the fill rate with FTEs within 40 hours. We are starting to chip away at some of the overtime, incentives, and agency work that we have had throughout the health system,” Thum says. “As we work to expand the SEAL Team in the future, we expect that trend to continue.”

Early data suggest the SEAL Team has affected nurse retention rates. “Within the first round of hiring that we did for the program, approximately 33% of our SEAL Team hires were internal hires,” Thum says. “These nurses were looking to leave the organization to do something different somewhere else. Instead, they applied for this program and were hired into it, avoiding their turnover to another organization.”

Further, a few nurses who had left Jefferson Health for lucrative travel jobs returned to the organization to take part in the new SEAL Team during the first round of hiring. Thum notes two or three more nurses soon will return during the second hiring round.

“There has definitely been a lot of positive energy and excitement around this team and the work team members are accomplishing,” Thum observes.

Thum adds he and colleagues on the SEAL Team have received positive feedback not just from frontline managers and supervisors in areas where the SEAL Team nurses are deployed, but also from staff nurses who work on these units.

Currently, the SEAL Team focuses primarily on acute care, working in critical care, intermediate care, or med-surg and telemetry, explains Thum.

“At the same time, we are ... looking at expanding SEAL Team services and recruiting members specifically for specialty emergency services — in particular, the ED and perioperative [services].” Thum also is considering other specialty areas for expansion, such as virtual nursing and safety services (e.g., one-to-one observation). In fact, he notes the one-to-one observation role would be more of a technician role. Thus, the flexible-resource-team approach could be applied to different types of personnel.

After the COVID-19 pandemic, the idea of injecting more flexibility into the workforce seems vital when planning for the future.

“If there are challenges at a particular hospital within our organization or throughout the organization, if we have flexible teams that we can deploy to areas where they are needed most, we will be able to better meet crises and demands,” Thum says. “If we have static teams that can only work in the locations that they are hired to, as an organization and as a health system we won’t be able to pivot and respond to demands or crises as easily.”

While Thum is an advocate for the flexible team approach, he urges anyone interested in deploying a similar solution to include all key stakeholders when designing such a program. Pay particularly close attention to the onboarding and education process.

“We expect [our team members] to come in seasoned and experienced; they know how to be a nurse. But we onboard them in how to be a Jefferson nurse, and really make sure they are comfortable and competent to practice in a different care area that they could be deployed to,” Thum concludes. “We certainly made some course corrections at the beginning of the program to make sure that staff get the onboarding that they need to be successful. I think that is probably the most difficult part of planning.”