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Bill Klaproth (host): The American Organization for Nursing Leadership or AONL is leading a national effort to develop a compendium of workforce best practices and innovations to aid and support nurse leaders. The AONL Workforce Committee sent out a nationwide call for exemplars from nurse leaders in all healthcare settings to share their best practices in local scenarios with particular attention to scenarios, including diversity, equity, inclusion, and belonging.

Before the COVID-19 pandemic, nurse leaders were challenged to staff appropriately and experience scope expansion within a dynamic work environment. The workforce committee and subcommittees evaluated best practices and innovations, structured recommendations, and set forth leadership opportunities and resources. Additionally, information was leveraged and gathered to define areas for future evaluation and research. The workforce compendium will go beyond published literature and focus on successful strategies used to effectively improve the work setting and support nurse leaders.

So, let's learn more with Rose Sherman, editor of the Nurse Leader, member of the AONL Workforce Task Force and lead of the subgroup on nurse manager recruitment and retention. Also with us is Claire Grant, Nurse Manager at Oregon Health and Science University in Portland, Oregon.

This is Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership. I'm Bill Klaproth. Rose, and Claire, thank you so much for your time. It is great to talk with both of you. Rose, let me start with you. So, can you tell us about the Workforce Compendium and the workforce challenge you sought to address and why?

Rose Sherman: Well, first of all, Bill, thanks for having us. The AONL Compendium is really the summary of work done by the AONL Workforce Committee. And while the committee really focused on a wide range of issues from recruitment of new staff to compensation to academic partnership, frontline nurse leader recruitment and retention, which was the work of our subgroup, was really a vital topic, and I think it's really top of mind for executive leaders today. No role in healthcare has really been more impacted than that of frontline managers who've really been the shock absorbers for their staff during the past three pretty tumultuous years.

And with nurse turnover right now at about 27% nationally, leaders are spending about 60% to 80% of their time just on staffing and scheduling. And their spans of control has really increased as budgets have tightened and more staff shift to part-time. Our nursing teams and our nurses have less tenure, so these leaders are really struggling to coach and mentor their new staff 24/7. And so, the leaders themselves right now are reporting a very high rate of burnout and turnover in the role. So, our challenge was really to try to figure out what we could do or what kind of recommendations we have about supporting them.

And so, our group really focused on three key areas. The first area we looked at was the redesign of the frontline leadership model. How could we really reduce the span of control for these leaders and better support their work? And then, the second area that we looked at was how could we actually support these individual manager through the initiation of things like nurse manager councils, executive coaching, peer support groups, giving them kind of an a communication channel to the executive team as well to share their concerns? And then, the third area was the centralization of nursing staffing and scheduling. Because it's such a big part of how leaders spend their time right now, is there a way that those responsibilities could be offset?

And so, your listeners may wonder, you know, "Well, you're not talking here about compensation and you're not talking about leadership development." But those were areas that other subgroups looked at, Bill, and I'm sure on future podcasts, you'll probably be interviewing them about their work as well.

Host: Yeah, absolutely. We are definitely diving into this topic and we'll hear from several people. So Rose, I love that phrase that leaders have become shock absorbers for the staff. That's a very visual way to say it. I love that. And you said, you know, certainly everyone is experiencing a high rate of burnout and turnover. And then those, three main points that you said, how to redesign the frontline, that leadership model, how do we better support nurse managers, and then centralization of nurse staffing as well, so that's really important. So, thank you for that, Rose. And Claire, so then what did you learn about this topic and how can nurses apply it to address or solve the main issue?

Claire Grant: Yes. Well first, Bill, thank you very much for having me on the podcast. Rose, it is great to be with you again and to have participated in this work for AONL. During our time together, we had interviewed nurse leaders from 24 organizations across the country. We asked them to respond with their best practices on how they are focused on nurse manager recruitment and retention. And what we found was really excitement and engagement from these nurse leaders in what they're doing in their organizations today. We learned that many organizations are actually piloting a variety of different strategies to recruit and retain nurse managers. And what we have found out, which is no surprise, is that recruitment and retention initiatives are not a one-size-fits-all endeavor. There are factors, such as your geography, facility size, clinical area, and organizational culture that can all impact success of those interventions.

So, we encourage people when we are thinking about how to implement some of these recruitment and retention interventions to acknowledge their variables at their workplace and consider looking at similar or like organizations when they are attempting some of these interventions. We also found that there are some organizations out there that are trying to reduce leadership span of control, which is a challenge in the environment that we're in currently with, the financial strains, health systems losing money, as well as nurses not applying for those leadership vacancies, yet organizations are adding assistant nurse managers and unit-based educators to help support those frontline nurse leaders. We also found that centralized staffing and scheduling have proved effective in some organizations, yet their successes really depended on the overall structure and availability of those resources.

Host: Right. Well, thank you for that. That makes a lot of sense. And Rose, let me turn back to you then. Why should someone listening to this podcast right now read the compendium?

Rose Sherman: Well, I think, first of all, I'd like to say that it's available on the AONL website. So if you haven't seen it yet, we definitely hope that you will go ahead and download it and read it. But I think, as I look at what we've put together, and I think the work group did just a fantastic job, after we did all these interviews, we also looked at the research that AONL had been doing with the Deloitte Group. Deloitte Consulting and also the Jocelyn Group. So, it's not only the interviews, but it's also other research that we've reviewed. And we made 10 strategic recommendations, but I'm just going to highlight a few of them. And then, Claire's going to really talk about some specific tactics.

Our first recommendation kind of adds on to what Claire just talked about. We really recommend that organizations really reevaluate the span of control and scope of the work of their frontline managers. I think it's very different today than it was pre-pandemic, and I think a lot of organizations probably have not gone back and really looked at what that really looks like.

I think a second recommendation that we had was that there really is a need for chief nursing officers in particular to have regular conversations with frontline managers to really assess the role challenges. I'm really struck by some of the chief nursing officers that we interviewed that said when they did this, they realized that the challenges were much different than they had been when they themselves had been frontline managers. So, I think that's an important opportunity there.

And then, thirdly, we recommend that you really look at some of these very time-consuming activities and tasks that our leaders are involved in, such as staffing, scheduling, and even picking up HR responsibilities during this whole COVID experience, pulling performance metric data. These things take a lot of time. Are there ways to offload that onto maybe other staff members that can do those administrative tasks.

Fourthly, we said, I think it's important to really reevaluate your frontline leadership structure right now. We saw in these interviews that we did, Bill, that a lot of organizations were adding assistant managers or unit-based educators, but not all. And where we are right now is that most of our units no longer have strong core teams. So, there needs to be more ballast on these units in addition to the leader.

And then, our fifth recommendation that I just wanted to highlight was we want to really focus on helping nurse managers to improve their own work-life balance. We found organizations that were allowing managers to work remotely one day a week or four-day work weeks. And so, these recommendations along with the information that are in these exemplars, I think, it's a good launching point to start the conversations with leaders in your own organization. "Everybody read the report and now let's go through what the recommendations are and how are they applicable in our environment." I think there's probably going to be ideas that really resonate, have the potential in your organization and others that might not be a good fit.

Bill Klaproth (host): And Rose, all of this information is in the compendium, right, as you mentioned?

Rose Sherman: It is. And it's free, and it can be downloaded. And even if at this point, you're not an AONL member, which we hope you are, but this is open to both AONL members and non-members.

Bill Klaproth (host): And you said it's also good for at least starting the conversation, right? Or thought leadership as well moving forward.

Rose Sherman: Yeah, that's the way I would use it, Bill. I would use it as a way to really start the conversation, because we don't have any expectations that you're going to put all 10 of these recommendations into play right away in your organization. But if there's one or two of them...

Host: Yeah. Even one or two of them, whatever would suit that organization.

Rose Sherman: For sure.

Claire Grant: I was going to say the nice thing is it's a conversation starter, like Rose mentioned. And when we talked to all these leaders across these organizations, they were more than willing to be a reference and resource. So, you'll read these small kind of summaries of the conversations we had with them, and then they provide their information in the compendium, so you can reach out and talk to them more about how you might look at this or implement it within your organization.

Host: Yeah. That's really good to know, Claire. So thank you for that. So Claire, let me ask you a question. For a nurse leader listening to this podcast, to you, what is the key takeaway and what are the key tactics someone can deploy in their organization? If someone wanted to get started, what's a good place to start? What are some of the tactics you would recommend?

Claire Grant: Absolutely. Well, I think the key takeaway is that time is now. We really need to address this nurse manager recruitment and retention and focus on and reevaluate the span of control and scope of work. Like Rose mentioned, the span and the scope of what nurse managers do now is so different than a couple years ago prior to the pandemic.

I started as a formal nurse manager in 2017. And I can tell you from when I started as nurse manager then as to how I manage now, it's, vastly different. So, I think just focusing in on this hot topic and addressing it now is so important. So, really just having it at attention. Please go back and talk about this at your organizations.

When thinking about the tactics, there's a few things that I kind of found in highlighting some of the themes that we saw across organizations when we were interviewing them. The first is listening. Take time to conduct those stay interviews with nurse managers across your organization to identify those retention challenges and the factors that are implementing why nurse leaders stay or why they're leaving. So first and foremost, listening. It doesn't take a lot of effort. You just have to sit there, listen and really be intent on what that person is sharing with you.

Next is presence. Really, Rose mentioned this, but encourage CNOs to have regular conversations with their frontline managers to hear those challenges and provide support. I was really excited and happy to hear one of the examples that we heard in our interviews was that of a CNO, Wilhelmina Manzano, from New York Presbyterian. So in 2022, so in this year, she conducted formal and informal conversations with 300 patient care directors, that's their name for nurse managers, but 300 conversations with the goal of these skip level conversations providing both coaching and supporting leaders who play the critical role in patient care delivery. So, just kudos to her. That's a great example of that. And I would encourage CNOs at other organizations to engage in that.

Another tactic is building that sense of community. If organizations can find ways to improve nurse manager support through tactics such as nurse manager councils, peer support groups and coaching, this could be incredibly beneficial. I think something we've learned throughout the pandemic is the sense of isolation and being alone is not one that any of us want to be in. So, building that community for nurse managers and frontline leaders is so important, so they have that network and that support system to move forward and to grow.

Another tactic that we found within these exemplars is giving back time. A lot of nurse managers will tell you they spend a lot of time in meetings. That was something that we wish we had touched on a little bit more. But looking at opportunities, right, Rose? Looking at opportunities to look at the requirements of managers in these meetings. And how many times do we hear "That meeting could have been an email." So, being really intentional about meetings that your leaders are at. Again, considering additional roles to nurse managers such as those assistant managers, nurse educators, and finding other resources to offload some of those time-consuming tasks, that are staffing, scheduling, et cetera.

Another tactic that we found that some organizations were focusing in on was work-life balance. So, thinking about those remote work days, 10-hour shifts, or flexible scheduling. Again, not a one-size-fits-all, but focusing in on your leadership group, your organization, how might you support some time away for your nurse leaders so that they have some balance between work and their personal commitments.

So, those are just a few things. Hopefully, those are helpful in terms of a few kind of takeaways that people can focus in on when they're reading the compendium.

Host: I think those are great takeaways. I like how you also said, Claire, time is now, and so much has changed since you started in 2017. So, that's really interesting. But your key tactics are really important. One, listening. I mean, that's very important. Presence, being present, building that sense of community. I love the giving back time. I love how you phrased that. I know we've all been in meetings. We're like, "Yeah, this could have been an email, but it took 45 minutes." So, giving back time is so important. And then, work-life balance, that's something that we all need to try to get a handle on. But it's nice that you're definitely addressing that, that is for sure. So, thank you for those great key tactics that someone can deploy in their organization.

So, Rose, when we talk about this, I know a lot of this is still a work in progress, if you will. But are there any measurable successes so far and anything surprising that you learned through all of this?

Rose Sherman: You know, I think that one of the things that we learned, Bill, is that as you said, it is a work in progress. But I do think there's some organizations that are starting to have some measurable results. I think that virtually every leader that we talked to, one of the metrics that they were really looking at was nurse manager retention. And some are really moving the needle on that, which is really great.

But we did have some other lessons learned from having done this work. I think while organizations are piloting strategies to recruit and retain their managers, I think most of the initiatives that we talk about as part of this compendium, we don't have the outcome data right now to say this is the best practice, because the data is just not completely there yet.

I think, as Claire mentioned earlier, and it's so important, is that organizational culture really drives ideas about leadership practice. And some leaders told us as part of these interviews that they encounter challenges with other executive team members, such as looking at four-day work weeks, looking at remote work. Some other members of the executive team might say, "No, you can't do that within this organization." so, there were some challenges around that.

I think that the span of control and responsibilities of the managers really differs across the organizations. For some, as an example, an assistant manager really was the best strategy for support. But there were other organizations that looked at it a little differently as they looked at the role, that maybe it was more payroll support, HR support, maybe they needed a unit-based educator. So, that's why it's so important to look at this and really think about it within the context of your organization because recruitment and retention initiatives are really not a one-size-fits-all endeavor.

Like, Claire said, you know, geography makes the difference. Facility size makes the difference. Organizational culture makes the difference. And I think that the centralized staffing and scheduling was a good example of an exemplary that was very effective in some organizations. But success really depends on the structure and really, to some extent, who's doing the centralized staffing? You know, what people are in there doing the staffing? So, there are other organizations that have real trouble implementing it.

So, I think the overall recommendation that we made, having looked at these lessons learned, was really for executive leaders to seek the input of managers and just get started. Be willing to take some small bets. Don't wait for the evidence, don't wait for the research, as Claire said. I think the time is now.

Host: Yeah. Just get started, and make some small bets as you say. And I like how you also said, you know, success depends on structure and this isn't a one-size-fits-all. So, those are all great points. Well, this has been a great discussion on just a wonderful topic, Claire and Rose. So, thank you so much for your time.

Before we wrap up, just wanted to get any additional thoughts from each of you. Claire, could we start with you? Any additional thoughts you want to add?

Claire Grant: Yes. Well, first and foremost, I feel very grateful for the opportunity to have worked with Rose and this group of nurse leaders on this really important topic that we're speaking to today. I've been following Rose since I started as a nurse manager, reading Emerging Nurse Leader, and just following her blog. So, it's been a pleasure getting to meet Rose through this process and how she's supporting nurse leaders in this way. So, thank you, Rose. I'm going to give you a shout out there.

When I think about this, again, I've been a nurse manager for five years and it's been a really difficult and challenging last few years for any nurse leader, let alone some of our nurse managers, those that are on the frontline, those who are newer in their practice as a nurse manager or those that are experienced. We've experienced so many challenges and hardships. And to me, this work and the compendium really kind of brings some hope and ways in which we can actually move forward. I found a lot of inspiration in these conversations with these nurse leaders and, to me, I'm really excited and hope that people engage in these conversations, take them back to their organizations and keep that conversation going. Do something. Work together, so that you can all move forward and strengthen the teams and the nurse leaders that you have at your organizations.

Host: That is really great, Claire. So, thank you for that. And I love how you say the compendium kind of brings hope and ways to move forward. And I think that's what everybody's looking for, both of those, hope and a way to move forward. What have we learned through all of this, how do we move on from all of this and move forward in a better way, for sure. So, thank you for that, Claire. And Rose, final thoughts from you as we wrap up.

Rose Sherman: Well, I think that I was really intrigued by the level of creativity and innovation by some of these health systems that we did speak to. I always think that the answers are within. And that's why it's so important really to get these discussions going with the managers because it's from those discussions that I think the executive team will learn where should they start. Because that's the overwhelming part, Bill. People don't even know where to start. It's like trying to take a bite out of an elephant. Where do you start with this? And the thing is that you start from where you are and you start from what you need most at this point in time. So, I would say, just getting back to what Claire said earlier, I think the time is now and I'd say just get started with the conversation and I think it's going to flow from there.

Host: Answers are from within. I think that is really insightful, Rose. So, thank you for that. And yeah, the old, "How do you eat an elephant?" One bite at a time. You just got to start, right? You just got to start in little small little steps, right? You just have to start doing that. And Claire mentioned that as well. You just got to start get some small wins going, and that's kind of how it grows. So Rose and Claire, this has really been fantastic. Thank you so much for your thoughts and your work on this and what you're doing for the industry as well. We really appreciate it. So, thank you again both for your time.

Rose Sherman: Thanks, Bill, for having us.

Claire Grant: Yes. Thank you for having us. Thank you.

Host: And once again, that's Rose Sherman and Claire Grant. And for more information, please visit aonl.org/compendium. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Today in Nursing Leadership. Thanks for listening