The New Definition of Flexibility - An Intersection of Nursing Leadership & Frontline Clinicians Insights

April 20, 2023

Riley (00:00:00):

Welcome everyone. Today's webinar, the New Definition of Flexibility and Intersection of Nursing Leadership and Frontline Clinicians Insights. I'm Riley Wilson with Beckler Healthcare, and thank you for joining us today. Before we begin, I'm going to walk through a few quick housekeeping instructions. We will begin today's webinar with the presentation, and we'll have time at the end of the hour for question and answer session. You can submit any questions you have throughout the webinar by typing them in to the q and a box you see on your screen. Today's session is being recorded and will be available after the event. You can use the same link you use to log in to today's webinar to access the recording. If at any time you don't see your slides moving or have trouble with the audio, try refreshing your browser. You can also submit any technical questions to the q and a box. We are here to help without please to welcome Jackie Ward, the Assistant Chief Nursing Executive and Senior Vice President at Texas Children's, and Dani Bowie, the Chief Nursing Officer at Trusted Health. Thank you both for being here today to discuss the future of our nursing workforce. And Dani, I'll now turn the floor over to you.

Dani (00:01:07):

Great. Thanks, RI. All right, here, let me,


Well super excited to be here today and talk about flexibility. This is something that's been top of mind for a lot of us in healthcare. We've seen it as a, as a trending headline over the past couple of years, and we certainly know that the nursing workforce is desiring flexibility and looking for that as they seek out employers and they continue to work with health systems. I also know health systems have been responding to this demand. We've seen some new programs arise, such as internal agencies building into unique specialty float pools to leverage flexibility and give that as an option to the workforce. I've certainly been on a mission myself in seeking out flexibility in helping health systems as I've designed different programs to move the needle. But as I've done this work over the last 10 years, I continue to have a question that circulates in my mind, and that is, you know, what does flexibility truly mean to the frontline nurses as well as to the nurse leaders and healthcare leaders who are in charge?


And so, to answer this question, I did a little bit of research and wanted to really seek out some truths, maybe uncover some myths that we have around the concept of flexibility. And to do so, I first did some comparative research here at Trusted. I lead a podcast called The Handoff. And the Handoff is a really great platform to help advance healthcare discussion, create community around innovation and new topics. And I decided to take a different approach with season seven. Season seven, seven was solely dedicated to nursing and the flexibility of the workforce. I talked with 14 leaders for 12 episodes, and of course, each episode had a, a bit of a different flare or take on workforce flexibility related to unique and innovative programs that health systems were implementing. But I brought one common question throughout, which was, from your perspective as a nurse and a nurse leader, what does flexibility mean to you and to the frontline nurses you serve?


Additionally, I also wanted to understand from the front lines perspective, what did flexibility mean to the frontline? So I created a two question survey and sent that out to the frontline. The goal behind the research was to cross analyze the results of the nurse leaders as well as the frontline to understand where there's alignment or maybe a little bit of divergence and perspectives around flexibility. To give a bit more perspective around, you know, who engaged in this and how they participated in the research. As you can see here with those, those 14 interviews that I conducted, we had health systems across the country. We had nonprofits, we also had startup companies, and a variety of roles were represented in those conversations. From the frontline perspective, we had 88 respondents engage in the survey. The majority of the respondents that we saw who engaged in the survey had about 10 years of experience, as well as came from the I C U or the ed, or the Med Surge Specialty Group.


 What's important to note here is that the frontline was not incentivized to answer any of the questions. They did this on their own, own free will as well as they worked across the country. So this is not representative of one health system, it's, it's a compilation of different health systems across the country and where those nurses worked. I first wanna jump into the perspective of the frontline survey and the results that we uncovered through the research before I head into the nurse leader analysis and then the comparative results, as I mentioned, I did a two question survey and I asked one question, the first question, which was having the frontline rank the most flexible work option to them. So as you can see, there's seven different options on the screen. And I wanted to know from the front lines perspective, what did you view as the most flexible?


As you can see here, by far, the most flexible work option that was selected was self-scheduling. What came in as a strong second was also gig work or working with no committed hours. So about 17% of the workforce said, we actually think that that's the most flexible work option. Additionally, for the second question, I wanted to understand the front lines perspective. What was the most important to them? So first we talked about what's the most flexible. Now we wanna understand what's most important to you in your practice environment. Again, what we saw was a common theme around self-scheduling that was the most important to the frontline. Additionally, what we saw with those seven work options that were offered for the frontline to identify as what was most important, we saw a tie between combination of shift lengths as well as part-time work, was was the number two option that was most important to them.


So keep those as top of mind. I'm gonna talk a little bit about the nurse leader results, and then we'll talk about the comparative findings for the nurse leader interviews. As I said, talked to 14 leaders for those interviews. And when I talked with every leader, there was one common theme that came through with all of those conversations, and that was that the most common trend is flexibility, is a highly personalized and individualized concept both for the frontline as well as for the, the leader in that it's often something that's like a snapshot in time and it progresses with the nurse as they progress through their career. So the example is, you know, a new nurse who's starting and they may desire to work as many hours as they can, they wanna make money, pay off student loans, et cetera. And then you have a nurse who's mid-career and they're wanting to advance their career, whether academically get new training, they may need more stability around their schedule and how they work so that they can achieve those goals.


And it's important for health systems to recognize that and continue to respond nimbly, which leads to my second theme, which is the workforce also expects a faster turnaround time from nurse leaders in those flexibility responses. And so what, what I mean by that, or an example is that oftentimes in the past, you know, it was it was common practice. Like three weeks out you would approve a PTL request or two weeks out a trade would be approved. Well, now the workforce is, is asking for qu quicker and faster turnaround time. And in fact, most every nurse leader said, and we're on board with that, and the key thing that they look at is ensuring that patient care is not disrupted in being able to offer those requests or act nimbly or flexibly to those responses. So I just thought those were important themes to call out.


Some other things that might be of interest to this group that's listening today is the identification of old and new programs to promote flexibility. We have Baylor programs mentioned time and time again, which is kind of a staple in managing weekend programs. And so it's an important concept and something to consider as you think about what do you need for your weekend, your weekend coverage, continuing to build into specialty float pools and we'll a bit more about that. But building up that flexible workforce in a new way is also something that a lot of health systems and leaders feel that is really important to continue to push the needle and flexibility. There's two programs here, and I'd be interested if anyone is doing these types of different programs that your health systems, I've yet to work in that environment. But one of our leaders mentioned how powerful it would be if we thought about actually hiring nurses and having them work a 10 hour workday.


But eight of those hours would be set for productive time caring for patients, and two hours would be set for non-productive time. So charting, shared governance, work, research, et cetera. It shows investment of the organization to help to continue to support nursing in some of the professional activities that are important to not only the health systems, but the community at large. And then lastly, salaried options. What if the front line also took on salaried options in addition to how the opportunity to hourly, we talk about organizational commitment and maybe there's, you know, a bit of challenge there. If we offered a salary option to the frontline with the understanding that they're committing to the organization, and we as the organization commit to that frontline nurse and career progression opportunities, et cetera, what would that do to our workforce opportunities? So just some unique programs, innovative, old and new that I wanted to mention.


And next we're gonna move into actually the comparative findings. So comparative finding, number one, self-scheduling. You saw it from the frontline nurse perspective. This was the most flexible option and it was the most important option to them. Additionally, when I talked with leaders across the country, this also aligned. Every leader talked about how self-scheduling was foundational to their workforce strategy and building and flexibility, which is music to my ears. I'm so happy that it's happening. They even talked about different shift links and the way they're getting creative. Some recommendations that I have around this is actually doing a bit of a deeper analysis to understanding is this happening at health systems across the country? Are we meeting the needs of the workforce? And also truly understanding what does the workforce, the frontline want from self scheduling? You know, is it the ability to truly autonomously pick up your scheduled shifts and not have them moved when oftentimes in self-scheduling, you still have some balancing activities that require some movement. But I'd love to a, also bring in, Jackie, I know you're here and hear your perspective of how T C H is approaching self-scheduling and your thoughts on what you're seeing in the industry in regards to self-scheduling.

Jackie (00:11:36):

Yes, Dani, I agree with you wholeheartedly that self-scheduling continues to be sort of the, the, the area that we need to continue to innovate and understand. And I think we're doing that at Texas Children's in a variety of ways. Listening to the frontline is most important, right? And I think we have a shared governance council called our Staff operations committee, and they help us design and impact what we do at self with self-scheduling at Texas Children's. So some of the things that we're doing across our organization includes obviously providing part-time per diem shared FTE type roles. One of our areas in intensive care unit is actually educating, meeting those nurses that are leading the self-scheduling committee to understand what does a leader feel self-scheduling is, and what does the nurse feel self-scheduling is, and kind of coming to a commonality of understanding so that they can build a better culture of self-scheduling on their units.


You know, as I meet with staff nurses a couple of times a month in what I call just Jackie, which is an informal meeting lunch with nurses, I'm hearing that there is a misalignment in what we believe self-scheduling is. But we have a host of ideas and strategies that Texas Children's from part-time per diem, looking at six hour shifts when you need that extra overtime shift, is it a shared responsibility between two nurses versus a nurse, you know, working a 12 hour shift. So there's a variety of things that we're doing, but we're having to peel back the onion to understand what does it mean for the nurse at Texas Children's when they say we want more autonomy and flexibility in our schedules.

Dani (00:13:20):

I really like that, how you're taking the approach of peeling back the layers and understanding what does it mean to your frontline as well as to your nurse leaders so that you can continue to create that commonality around such a foundational practice. So that's fantastic. We're gonna move on to the second finding, which was actually an interesting finding. So gig and part-time options. So as you think back to the response of the frontline and what they were looking for, for top choices of work options that were flexible, most important to them, we saw a unique trend in theme was, you know, gig and per diem was viewed as one of the most flexible options. And then part-time work was also viewed as most important to the frontline. When I talked with leaders in the Handoff podcast around flexibility, a lot of these programs weren't the leading strategies or mentioned.


Now that doesn't mean that that's not happening at their organization. These were 45 minute conversations, but it does show a little bit of divergence in the priorities of the leaders and the priority of what we're starting to see in the front line in regards to these flexible options. And, you know, as we think about this new space of gig and part-time, there were some recommendations that I thought would be helpful for health systems to consider, and one is to evaluate your workforce composition. So looking at how many frontline staff do you have as full-time, part-time gig per diem, or even your float pool. Looking at that workforce comp, the more you have in flexibility, typically the less you need reliance on external agency. So it's really important to start to build into a new model of workforce composition to build that flexibility. Additionally, there's been emergence of new technology around the space of gig and part-time work to make this easier for management for health systems, reduce that administrative burden and have, have understanding of who's working these shifts as well as onboarding, et cetera. So starting to be a game changer and making oftentimes what I found to be challenging programs to manage more realistic and doable for those health systems. Jackie, I would love your perspective on getting him part-time and also some of the things you're doing at T C H I think are really meaningful.

Jackie (00:15:37):

Yes. And I'm sure there are lots of nurse leaders that are listening, and I know that you can attest that in your organization at some point in time you've had a list, right, of names of nurses who wanted to go part-time or per diem, but just weren't able to do that because of staffing constraints or FTE constraints, et cetera. But we are pivoting at Texas Children's in understanding the reality that those lists don't align with retention when it, when you think about our nursing workforce. So we are really stressing the part-time per diem work. We've traditionally been an 80 20 type of an organization and really pushing the boundaries to the 70 30. I think it's really important that we meet our workforce where they are because their lives things change, and so their expectations change and their needs change. We're also embarking on creating a more ideal shift based on our tenured nurses.


So as we continue to see our experienced nurses stay with us for extended decades, which is what we want, these nurses are not always able to work the shifts that they maybe have been hired to work. So looking at that 12 hour shift model, looking at the three day a work week model we need to be able to maintain that intellectual capital from these nurses who have such high expertise. And so we're really being very innovative in that approach, especially during a time when our experience mix has shifted a little bit due to the pandemic and all of the challenges that we've ex we've experienced in that. So we are supporting our experienced nurses in a variety of ways, and we'll continue to innovate in that, in that platform. Hmm.

Dani (00:17:17):

I like how you mentioned the ideal shift. Every time I talk to you, Jackie, it's like a new concept arises or some new innovative program. Oh, that's awesome. So thanks for bringing that up. We'll move on to our final comparative finding before we move over to the T C H story. And I just wanted to call out the concept of cross-training and how shocking this finding was to me when I reviewed kind of the front lines perspective that cross-training was considered the least flexible option as well as the least important. So, you know, that that made me do a little bit of soul searching. A lot of leaders that I spoke with during the handoff podcast discussing flexibility. You mentioned some innovative programs around giving the workforce diverse experiences, upskilling some dual roles. So, you know, I would hesitantly say this calls out some misalignment between the frontline as well as the leaders.


Or what we also would ask is that we conduct a bit more research around why was cross-training viewed I think in my perspective, negatively from the frontline and not viewed as a flexible option. And so that was just something that I think is important for us to consider is how do we take into consideration the front lines perspective around this cross-training space. It also, you know, shows the importance though of continuing to build those large specialty float pools. And that is kind of a sweet spot of creating flexibility for health systems, but also still meeting the need of the workforce, wanting to maintain specialty expertise and growing in their area of specialty knowledge. But Jackie, I would love your thoughts around this finding in particular.

Jackie (00:19:02):

Yes. And Dani, I can't wait to see the additional research on this because I agree with you that the concept of cross-training needs to be demystified because I really believe people may align the word cross-training to floating. And, you know, floating has been an age old dissatisfier in the nursing world. And so some of this may just be a little misalignment, but cross-training has been successful at Texas Children's in some of our subspecialty areas. It's important, it's essential to be able to scale, you know, your workforce. So when you think about the strategy of pre pandemic most certainly during the pandemic, we had to rely on cross-training. And it was an invaluable strategy during our pandemic strategy. So I just will share with you one example of that. We, we do have a float pole in the ICUs.


We do have a float pool for our acute care, but in our ICUs, particularly our heart center that have a step down unit, they've cross-trained the entire stack so that they can leverage those resources and upskill a nurse that is in a step-down unit to fill those gaps, those staffing gaps in the icu, particularly the cardiovascular ICU when needed. And these are the nurses that have that affinity for additional growth and development and want to be in a high acuity area, but wanna also have that balance right of the stepdown unit. And so this was an in an innovative approach that we took. I also mentioned to you previously that we had a tandem nurse model during the pandemic, and we cross-trained acute care nurses and they went and worked side by side with ICU nurses during that time. And this model is still being used in one of our community hospitals. Even it was really needed during that time of workforce shortage during the time of the pandemic. But I believe cross training has a place I do agree we need to demystify it because I do think it's gonna be valuable as we continue in healthcare.

Dani (00:21:00):

Yeah, yeah, I agree. Demystifying this one. And I think digging a bit deeper, which comes to the conclusion of some of the research findings you know, I wouldn't, it wouldn't be prudent of me not to mention that there are some limitations. And you know, the sample size is a little small. I'm sure we can create a bit more rigor around this. The intent behind this initial research was really to do just what we're doing today, have the conversation, what is flexibility mean, and the hope is that we'll take this a step further and continue to advance the research and the work around flexibility. I'm committed to solving this here at Trusted. We want to understand what flexibility means, and I would love it for those listening to take some of this, these learnings and move them further into the research category. Just one thing to know is these findings will be available in nurse leader. So we have published around this research, and it'll be available shortly online and in print. And it's demystifying workforce flexibility. I'm gonna hand over the presentation to Jackie, who's gonna share some of their innovative workforce programs and strategies and how they've been leading the way in the future of nursing at T C H Jackie.

Jackie (00:22:14):

Thank you, Dani. I am really honored to be able to share a little bit about what Texas Children's has done as it relates to our workforce. You know, being a 29 year tenured employee at the largest pediatric and women's hospital in the country has been really a rewarding experience. This is a photo just to give you a little background on Texas Children's of one of our locations in the Texas Medical Center, which consists of nine buildings. This is sort of the flagship of Texas Children's Hospital, but we span over 120 locations across Texas, yes, across Texas. We now have 20 locations in Austin, Texas, and will be opening our first hospital there in February of 2024. We're very proud of our ranking of number two by US News and World Report. I am proud as the system Chief Nurse Executive to say that we are a magnet accredited and have been since 2003. And of note, less than 9% of all organizations have the magnet accreditation, which is the gold standard for nursing practice. And less than 1% have more than four accreditations. In this week. We will hear about our fifth designation. We are our growing organization. When we get into Austin, we will have over 20,000 employees, and we have over 4,300 amazing nurses taking care of our patients in our community.


So let's talk a little bit about, since we're talking about workforce, what did we do at Texas Children's as it relates to our workforce and developing that pipeline? You know, the pandemic required us to have a very introspective approach to our workforce. We are a people-centric organization by culture, but the pandemic required us to approach our workforce stabilization very differently. We, as a nursing leadership enterprise developed tiger teams around our strategy for stabilizing the workforce. And this included retention first and recruitment as we were not immune to the challenges that were happening around us based on the pandemic. So we wanted to build a healthy pipeline. And so I challenged the team to develop a, a strategy that we needed to hire over 500 new nurses in a year. And this was really targeted around our graduate nurse recruitment program, along with an experienced recruitment strategy, because we never wanted to not recruit experience nurses, but the graduate nurse was the pipeline.


And so we have a very strong partnership with our academic universities in the Texas Medical Center. And so through that partnership, we were able to get more student placements here at Texas Children's and really to be, to build a program where we can get those students in earlier. So what we did, we developed a grow your own strategy, right? We we hired student nurses. We were allowed to able to enculturate them into the Texas children's system so that when they graduated from nursing school, they had already been in our system. They were already aware of our culture, our workflows, and they had built a relationship with their team members on those floors and could moved seamlessly into a graduate nurse role. So they were ahead of the game before they were graduating from nursing school. So this allowed additional career growth and progressive programming for them.


From a workforce perspective, we are currently reviewing how we did from a retention perspective with this pipeline strategy. So when you talk about retention, obviously everyone's focusing on maintaining their nurses. But when we talk about building a healthy pipeline, it is essential to have a solid retention strategy. And that is what we have at Texas Children's. I'm very proud of where we have gone and where we're going as it relates to our retention. As you see here, the national average for nurse turnover is anywhere between 25 and 27%. Texas Children's sits proudly at 13.6% today, and this is nurse turnover. From an organization perspective, we're sitting right at about 14%. We have a goal of always being less than 10%, and we'll get back there, but we know that we are really pleased to see where we sit today. It's pretty remarkable. So how did we get here?


So I say that because any retention strategy that a department focuses on has to have the organizational leadership that says retention is our, is an important strategy. So our focus on our workforce, it was very challenging during the pandemic, but our president and C E O Mr. Mark Wallace led the way his very people-centric leadership was on full display during this unprecedented time that we were experiencing. And it mattered so much to our workforce. I remember vividly the day he called me and our chief Human Resources office, Linda Aldridge into his office, and he said, our workforce is challenged. There's stress. What are we going to do? We need to help them personally and professionally. And he says, come back with a plan. And that is what we did. We developed the tomorrow together 1, 2, 3 retention program. This was debuted in 2021 solely for the entire workforce.


We did not say just for nurses, this was for the entire workforce. And what did we do? We spent over 160 million as an organization to support our employees through a 2% salary increase pay time off that was given to them for one week. We implemented additional programs leadership committed to being on the spot visible to our teams. And it was significant. And he always says, there is always enough money to do the right thing. Now, this was the foundation for the nursing workforce retention programs. It was, it allowed us to be catalysts to doing additional things. And so what I've done in the nursing workforce, along with my amazing team, is we have four things that we've done. We knew that we had an inexperienced workforce. We're hiring all these graduate nurses. We knew that their experience was not the same as nurses that had already been hired.


So we created an instructor role. And what is this role? I call it the wraparound services role. So this is a role that is independent of the preceptor. It is independent of the charge nurse. It is independent of the leadership team. This role does not have any patience, and they are there to be hip to hip support for a new nurse that is off orientation. So the instructor role, this person will go up to a new nurse and say, what's your assignment like today, Jackie? What are you anticipating for this patient? Any concerns that you have, if anything comes up that you need my help, I'm here. Call my vote phone. And this role has been very instrumental in supporting our inexperienced nurses on the floor. I also implemented a nurse retention specialist role. We have two of them in our workforce. And this role was created to be able to support our leaders in developing strategies, analyzing exit data, creating plans in partnership with the frontline leaders in order to improve retention on their units.


And they have done an amazing job, as you can see with our turnover rates. And this is in direct partnership with the leadership team. The third is really focusing on our multi-generational workforce plans. You know, ensuring that we can meet every nurse where they are, regardless of it experience, regardless of age is our is our strategy. So we are creating flexible staffing schedules, as I've talked about, and really creating additional strategies to be able to help our tenured nurses be a support and for us to not lose their intellectual capital as they age in their tenure here at Texas Children's, we will continue to create expanded roles for them to work in. We also have created a retired nurse program so that we can continue to have them pour into new nurses so that we don't lose them as they are not always ready to stay at home. They wanna stay engaged. And obviously our shared governance council, we have nine shared governance councils that are led by frontline nurses and frontline nurse leaders. And so we listen to them because it is important for them to have input in decisions that impact their work. So between these four sort of components of our retention programs, I think this has been sort of the foundation for what we've done alongside strong frontline leaders that are impacting the success of our nursing team here.


So as I continue to focus on retention, staffing continues to be the area that we want to continue to focus on. So creating a dynamic staffing model to ensure the success of our frontline nurses so that they can cont deliver high quality care is a forefront for us. So when I say a flexible staffing model for internal staff, it is moving from the 80 20 to 70 30, really wanting to meet the nurses where they are, give them more flexibility, part-time perm expanded roles. Going back to what we shared, Dani, is promoting self-scheduling. Is it really self-scheduling? Do they really get to put the days that they wanna work, balance it amongst themselves and meet those parameters that their leadership needs them to meet. Embracing the use of workforce technology. You know, understanding where, where are we with our skill mix? What do we need? What do we have? What workforce do we need to target using that technology? And lastly, augmenting our staffing with that whole gig staffing model concept, right? We've gotta be flexible, we've gotta meet them where they are, and we've gotta be able to meet those fluctuations. I call 'em surge in census demands.


And we can do that through deployment of flexible on demand, external labor pools. You know, we ha I met the, the owner of Trusted Health six years ago, and T C H has partnered with trusted on an innovative build on demand external labor pools. And it's been very successful for us to meet those census demands. And when we feel that we've got, you know, these leaders on the call leave of absences, when you've got non-productive time that's high, you need to be able to fill that gap. Trusted Works technology has enabled us to really be nimble, to be able to onboard experience nurses in a very efficient way, to understand who they are, what they provide their credentials and expertise in an automated format. It's re very reliable and has allowed me to have a very cost effective staffing financial workforce model. I can't take my eye off of the financials, and this has really allowed me to be able to do that, and it really allows us to have control over how we manage our supplemental staffing model.


And lastly, I will just share where we're going in the future. It is extremely important for any nurse leader to focus on developing a healthy, diverse, and thriving workforce. And when I say diverse, understanding that your generations, you may have three, maybe four generations in your workforce and to really be able to appreciate all levels of that generation. And we are continuously going to be the top destination for our nursing talent. We feel that we are a career destination. You don't come here for a job, you come here for a career. And many of our nurses, all of our nurses express that we wanna continue to create opportunities for a full career. When I say that I've been here 29 years, it'll be 30 years in September I've had a full career. And that is what I want for all of the nurses that work at Texas Children's Hospital. We're going to continue to create innovative pro partnerships such as trusted Health and technology to redesign the future of our nursing workforce, because that is where healthcare is going, and we are gonna be on the forefront of that. And at this time, I will turn it back over to you, Dani.

Dani (00:34:57):

Thanks, Jackie. I just, like I said, every time I listen to you talk, I learn more and more and I love the innovative programs, the wraparound services instructor roles the Tandem nursing model. It's fantastic. You know, I just wanna mention, as we talk a lot about the research and the desire for flexibility from the frontline programs that are important for health systems to consider self-scheduling gig programs, float pool, specialty opportunities et cetera, it's imperative that health systems also consider technology and how that also can help create effective and scalable operations to allow for flexibility. And so works. Flex is our technology here at Trusted with the ultimate goal of giving health systems the ability to create that flexibility both internally and externally for your labor. We automate the onboarding credentialing process that's important for your workforce. We also automate the process of OpenShift notification management and the ability to really deploy and staff the workforce.


The administrative burden that oftentimes nurse managers and leaders have in doing this important work is significantly reduced so that they're not spending time calling or emailing people. And we have the ability to manage this and really get the tools in the hands of the leaders and the frontline to give them that autonomy and control over their schedule. So it's just really important as you think about your flexible programs, your innovative strategies for retention, growth, and recruitment to also consider the technology that can help play a part in transforming your workforce in that space of flexibility. And so this is just brings us to the conclusion of our presentation around the workforce. You know, as you heard Jackie share, the workforce strategy requires some of these foundational programs like self-scheduling tech, and as you can see with Jackie, courageous leadership and organizational commitment to bring that to life.


 And, you know, there isn't one solution that makes this it's, there's no golden, you know, golden rule that's gonna solve it all. There's a variety of things that we need to consider here. And then the rise of gig economy cannot be overlooked. It is a space that's trending in healthcare. The frontline is asking for it. Technology now can support it, and it will help bring another layer of flexibility and staffing, you know, transformation to healthcare that we haven't seen before. Jackie, I would love any of your final comments as well as we conclude this session.

Jackie (00:37:35):

I agree with you, Dani. I think this is one of the areas that nursing leaders and healthcare organizations must continue to focus on, right? The workforce. I think as the workforce changes, as people leave the workforce who've been in it for a long time, being a healthcare experts, we're going to have to figure out ways to maintain that intellectual capital in our healthcare organizations. It is a shift for many leaders. I think the, the word courageous leadership, thinking differently and leading differently as our C E O tells us often is going to be the mantra that has to be embraced. And I think Texas Children's will continue to lead the way and, and can share how we're doing that, our successes and our challenges, right? But I think this is an area that we all can combine and be unified with.

Dani (00:38:29):

Perfect. Thank you so much. We're gonna hand it back over to Riley who will help moderate the q and a session for both Jackie and I.

Riley (00:38:40):

Great. Thanks Jackie and Dani for a great presentation. We'll now begin with today's question and answer session. You can submit any questions you have by typing them into the q and a chat box on your webinar console. We'll get started with the first question here which is, can you explain a little bit more about what GIG stands for in nursing?

Dani (00:39:01):

Yeah, I'm happy to take that one. I think that's a great question and it, it definitely is a, a trending, you know, theme that we've seen here in healthcare Gig really is kind of like a per diem role. So it means that you do not have an FTE e oftentimes with that health system, you're hired at a zero fte and usually each organization has some type of respon organizational commitment defined. So that could be one shift every schedule period. It could be one shift every week. There's a variety of ways that I see this defined by health systems, but ultimately it's, you don't have a committed F T e other than this commitment of maybe one shift a week or one shift every schedule period. But Jackie, I'd love it if you could give some explanation as well as how you define gig at at T C H.

Jackie (00:39:49):

Yeah, so I will say at Texas Children's, we haven't really coined it as gig just yet. I think it's really around having that flexibility that's associated with the word gig, right? It's kind of that on demand. I can, I can sign up for shifts. I'm not committed to anything. Particularly I think that is, it's the new word here at Texas Children's that we are, we're really figuring out, but I think it's more of the on demand in, in the Texas children's lingo.

Dani (00:40:20):

Yep. Another good reference there.

Riley (00:40:24):

Great. Thank you both. Our next question is, have you seen hospital setting some standards for the number of full-time versus part-time staff composition?

Jackie (00:40:36):

Sorry, go ahead, Dani.

Dani (00:40:39):

Y yeah, I think this is, and I, I'm ho ho hoping I'm interpreting this correctly. Usually the workforce comp that you mentioned, Jackie. So we typically see the 80 20 rule, 80% full-time, 20%, maybe a part-time composition, and that that needle is moving where health systems are looking at more of a, you know, 70 30, 60 40 where that 30 or 40% is really a part-time. It could be the, the gig per diem on demand workforce that Jackie was talking about float pool as well to build in that flexibility. But as you Jackie maybe wanna elaborate one more time around how you're addressing that at t c with moving from 80 20 to 70 30

Jackie (00:41:18):

Mm-Hmm. <Affirmative>. Yeah, and I think it, I'll be totally transparent. You know, it's, it's, it's challenging, right? When you're shifting someone from working three days a week to two days a week or one day a week if you're going to per diem. But where I challenge the team is that I'd them work two days a week than zero days a week. Because in this competitive landscape if a nurse needs to have that flexibility for whatever reason, family school, they're going to find it. And there's a place that's going to accept them to get that. So why don't we meet them where they are? So I don't think in any, and both of those things are true, and I think some units have, units have different cultures, right? They have different scheduling needs, and I think each unit having a understanding of where can, how far can they go with a 70 30 or 60 40, I think depends on how that unit's fa fabric is made up of their FTEs. And I give my team as much autonomy as I can for them to be able to do that to meet their teams where they are.

Riley (00:42:26):

So on that same topic of staff composition, could you explain a little more about what is 80 20 versus 7, 8 30? Is that skill mix or is that full-time versus part-time?

Jackie (00:42:38):

For us it's full-time versus part-time.

Dani (00:42:42):

Yeah. And that, and that's how we're defining that in this presentation, is looking at the full-time, part-time composition. Skill mix is a, I like how they're thinking whoever asked the question, you know, thinking also, not only is it your FT status, but then also looking at your holistic workforce and, you know, novice to proficient and the skill mix needed to care for your patients. But for this presentation, it really is allowing for flexibility around more of the per diem on demand space versus, you know, just full-time work.

Riley (00:43:18):

So you both, you know, highlighted the importance of self-scheduling. Could you talk about the perspective of frontline workers versus leader perspectives when it comes to self-scheduling for weekends and holidays?

Jackie (00:43:32):

Hmm, that's a good one. And I think when we conquered that we can all write a book book about it. You know, I've been a nurse almost 30 years and the weekend program has, you know, it's, it's been in vogue, it's been out of vogue. You know, some organizations at one point felt it wasn't, it wasn't providing what it needs, but I think there is still a place for these types of programs, right? There are nurses who need to work weekends because of younger children or they're going to school. So I think there's a, a, a place for that. I think weekender programs allow flexibility across a unit. And so we are really thinking about where do we go. We still have nurses that are on the weekender program, but we've tried, we've been phasing it out, but I think it's time to maybe even reassess, are we at a point in time in our workforce where we have to go back and, and re-look at the value of a weekend or program because it it, it's valuable for the nurse working it and it's valuable for the ones not working the weekend.


 And so I think that's an opportunity for us to look at that.

Dani (00:44:47):

Yeah, absolutely. I, I think you hit the nail on the head when you said it's been in vogue and out of Vogue. I, I have seen it in the industry off and on, but it, as we mentioned, workforce strategy requires multiple approaches. And so it is a good program to think about if you are struggling to cover your weekends. Some health systems have union, you know, expectations around how many weekends you work, some don't. But if you do an analysis and you are struggling to meet weekend coverage based off of census and who you have available to schedule, it is a nice way to augment your workforce as well as find a workforce that maybe that works for their lifestyle as Jackie was mentioning. So it's just something to consider in your arsenal of, you know, programs that you can use to bring some staffing help as well as some flexibility to the workforce that they're looking for.

Jackie (00:45:37):

Yeah, I would highly suggest people have a portfolio of staff, of a staffing model that they can flex up and flex down and, and really have some diversity in their staffing model.

Dani (00:45:52):


Riley (00:45:53):

Great. Thank you both. Our next question is, what is your advice for a smaller clinic that has fewer nurses but would like to build in more flexible scheduling? How can you manage the operational needs while allowing greater flexibility for staff?

Jackie (00:46:08):

Yes. It, it comes very difficult when you're in a smaller setting because you have less staff to really be flexible with. I think what I would suggest for that leader to do is sit down with those frontline nurses and find out what does flexibility mean to them. Maybe there's an ability to go to some 12, some tens even in clinics. We have some clinics at Texas Children's that are 12 hour day clinics based on the type of clinic it is. And so I think really assessing with those nurses, what does flexibility is, what does that mean to them, and what are they desiring? And work in partnership with them to determine how you can meet their needs. That would be my first step. And then understanding what's feasible within your FTE pool that you have in order to be able to meet their needs. Some things you just can't do, some things you may have to expand and, and look at, do you have the ability to leverage other resources in another clinic that has a similar specialty or skillset? There's just so many innovative ways, but the first step would be to sit and talk with those nurses to figure out what is their true need and how to provide them that flexibility within, within the parameters that you can without impacting patient care.

Dani (00:47:25):

I think Jackie answered it quite comprehensively and well.

Riley (00:47:30):

Great. So Dani, you spoke, you know, about the importance of cross-training. Our next question is what is the purpose of cross-training, if not for floating between units? Can these two things go hand in hand?

Dani (00:47:45):

It, it, can you repeat that question again? <Laugh> looking for that? Sure. Yeah. Thank you.

Riley (00:47:52):

Yeah, so the question was what would be the purpose of cross-training if not to float nurses between units? Can these two things go together?

Dani (00:48:01):

Yeah, yeah. Okay, great. Cross-Training and, and that's where I mentioned, you know, there's some questions around the research. So the, all the interviews can be found on the handoff podcast. And the leaders that I spoke with across the country, now, as you think about cross-training, we saw that the frontline, you know, that just they didn't view that as the most flexible as well as the most important. It was the least on their options that they chose. And I think it's important to further define that research, to know really what it means to the frontline. Floating and cross-training are different in the sense of, you can think about cross-training for upskilling, right? Looking at dual roles. You could be a preceptor as well as have skill on, on your unit caring for patients. So there's a, there's a broader term, I think, around cross-training, but they do dovetail together.


And so it is important to be able to create cross-training programs that allow for floating. And you can even think creatively around like critical care and ED and is there a program where people can self-identify and get that cross-training with the understanding of floating. So it, it is, I think, a complex topic that needs to be peeled back a little bit more to understand the desire of the frontline and the needs of the health system. But that is kind of where my head is at, is that, you know, cross training is pretty broad and floating is a kind of a, a responsibility and duty of the nurse per organizational design that also needs to be taken into consideration. But Jackie would love your thoughts on this as well.

Jackie (00:49:34):

Yes, and we, we've done that between our ED and our ICUs. One of our, our director and our EC partnered with our ICUs. And really it was, it was sort of birth off out of the, let's understand what each other does, right? It, it actually helped each of the areas understand better how their areas worked, but it also allowed nurses to be able to upskill themselves and to be able to support an I C U when they, when it's needed even though they work in the emergency center as well as to expand their knowledge because those critical patients come through the EC first before they get to the floor. So it was really a win-win on both sides. But I agree, I think cross training, there's something to be said about it. I think there's a place for it. I think we just need to demystify the fact that it is aligned with floating, which is a a not so satisfying part of our work as nurses.

Riley (00:50:34):

Great. So our next question is, have there been, has there been any research on the change in call rates when flexible programs are in place and working?

Dani (00:50:44):

I saw that question and I highlighted it. The answer I have to, that is I do not have any research personally around that, but I wanted that question to be asked because I thought that that was an important piece of research for the future. So thinking about as we develop these flexible programs, looking at your call rate, which my interpretation was like call offs and who is the engagement of the workforce for those areas that have these flexible programs. So I have not had any research around that space of call rates and these flexible programs. But Jackie, if you have or have seen anything in your health system, I, I thought it'd be interesting to ask.

Jackie (00:51:24):

Yeah, we have not done any research or looked specifically at that data, but I do have a sense that for nurses that have part-time in per diem roles, that they call out less because they have more flexible, they have more flexibility. I think that also goes to the other question that I saw in the chat around having a more flexible workforce. Does it impact quality at all because you have changes, you know, instead of being there three days a week and having that sort of consistent care model then you may have a patient may have a couple of nurses in a three day stay. And so I do think that that is something else to look at to ensure that we're not impacting quality care and also to ensure that we are giving our nurses what they need in order to not impact the quality of the care they're delivering.

Riley (00:52:21):

Thank you. So Jackie, you mentioned the instructor role that you have at Texas Children's. Is this role to support new nurses on one unit or does this instructor cover multiple units?

Jackie (00:52:35):

So here we, that role covers one unit. We created the role when we were building our legacy tower, which is our ICU tower because we were onboarding hundreds of nurses for our new ICU tower. And so we knew the experience level would be a little off when we were opening. And so this instructor model was created as, as related to the, our orientation process to ensure that our nurses felt supported, that they felt that they had the knowledge and they had the expertise and that they had the resources available to them to be able to deliver care. So it is one unit at this time.

Riley (00:53:21):

Great. So our next question is, you mentioned the data, this presentation stemmed from 12 nursing leader executives. Can you say any more about who each of those executives are and how their current roles reflect their inputs?

Dani (00:53:36):

Yeah. great question. So these, these inputs from healthcare leaders all over across the country, but it's actually, if you look at the handoff podcast and season seven, which is airing right now, that is the the lineup of leaders that we talked to across the country. So we had some from large health systems, small health systems startup companies. They range the, those that interviewed range from roles of executive director to ceo. So broad range here, but the lineup is in the handoffs season seven podcast.

Riley (00:54:16):

Great, thanks. We have another question on self-scheduling. How do you handle the dynamic in self-scheduling when there are a few staff members who never get their schedule in even after multiple reminders? There are other staff members spending time trying to make it work for them at the last minute.

Jackie (00:54:34):

Yes, there's always one or two, right? That has been an problem. So what we are doing is we are giving our nurses the scheduling committees or the liaisons that have been created in several of our units. They've been trained on what the leader would like to see from a schedule, you know, how to work with the staff using those constructive words to be able to talk to the staff on how to get those things done. So what we're asking them to do is manage it within themselves, right? Because self-scheduling cannot be that when it doesn't work, the leader then comes in and has to fix the problem. We want really, we want the teams to be autonomous and to work as a collective group at the staff level to, to fix those issues and to have that feedback, those conversations with their peers. Now obviously when that does not work, then the leader will need to get involved and engaged and, and really have a conversation with the nurse regarding why is that the case? You know, what can they, what can be done to assist her or him in getting their schedules in on time? But really the goal is for that team to work together as a frontline team to ensure that that schedule gets completed in a timely manner so that it can be published

Riley (00:55:56):


Jackie (00:55:56):

Your feedback is always best.

Dani (00:55:59):


Riley (00:56:03):

I think we have another question on the instructor role at Texas Children, Jackie. How many instructors roles do you have?

Jackie (00:56:11):

So it's growing. We have instructor roles in our ICU units, so there's probably three across a few of our ICU units, cuz not all of them, them. And then we've just expanded into our acute care areas. We have a couple of floors that have instructor roles and then we do also have in our nicu. So I would say probably six grow into eight in some key areas. Not every unit has an instructor role. It's really where that inexperience, that that skill mix is a little off and where there's a high low, high volume of onboarding of new nurses.

Riley (00:56:59):

Great. our next question is, how has technology helped enable a per diem staffing model? If it's helped at all?

Dani (00:57:09):

I think that's a really great question. You know, cause we talked in this presentation, the rise of gig per diem on demand economy that's happening in the industry. I'm sure many of you on the, on this presentation and listening have managed per diem or on demand, and it can be challenging because you have to onboard, whether it's internal and external, you have to ensure that competencies are set to your organizational standards as well as then deploy the how do you get those open shifts to that workforce. And so technology, I believe is cracking the code in this space and making it a reality where in the past this was still very manual required spreadsheets to manage and phone calls and text messages to make this reality with technology like works. And our ability to bring it into one platform so you can credential onboard internal and external workforce, and then actually the day of staffing and the deployment of the shifts can be automated and sent via app. So the workforce can accept and then, then it goes back onto the schedule. So the workload of the manager is significantly reduced and the visibility of the workforce accepting shifts has been, you know, elevated. So you can see it across your organization and you know, who's working, what shifts. So it's just really reduces that manual burden on the managers.

Riley (00:58:29):

Great. Well thank you both for your answers. I think this is gonna be the last question that we have time for today. So how do you recommend going about change management and bringing these concepts to current clinical leaders who may be more closed off or not as open to these concepts?

Jackie (00:58:46):

That is a really good question. <Laugh>. I think it starts with understanding that this is the, this is where we're going in healthcare. I think if the leadership cannot be courageous and embrace the fact that our workforce is, is who we should be listening to because they're our most important commodity. When you think about the business we're in and taking care of patients, we are pressed to meet our workforce where they are. And I think courageous leadership means changing how we've traditionally thought about things, right? Nurses that have been around like myself 30 years have had to change how we think about meeting the workforce and being more flexible. And I think if we're gonna be successful in healthcare, then that is what we're going to have to do. It is, it is imperative that we look to our workforce and begin to think about what they need from a personal and professional perspective.

Dani (00:59:49):

Yeah. Yeah. This one is a loaded question. I would just say drive with shared governance opportunities, frontline perspective, educate, educate, educate. And then hold PD c a cycles. So what was the success of the programs? You implemented? The feedback of the users and adjust. This is not a final destination, it's a journey and it will be ongoing from this point forward. And so that's the things I've learned as I've led these, these programs. Thank you for the opportunity to share.

Jackie (01:00:19):

Yes. Thank you.

Riley (01:00:22):

So that is all the time that we have for today. I wanna say thank you to everyone for such wonderful questions. Thank you to Jackie and Dani for an excellent presentation and to trusted health for sponsoring today's webinar. To learn more about the future of nursing, please check out the resources section on your webinar console and fill out the post webinar survey. Thank you all for joining us today, and we hope you have a wonderful afternoon.