Rare is the nurse or physician who does not cherish to be challenged every day to the full extent of their education and experience in service of their patients’ well-being.
The opportunity to focus that skill on helping people is why most clinicians went into healthcare. They can perform at their best if they’re unencumbered by peripheral tasks that distract from clinical decision-making and direct care. These distractions can erode morale and cause burnout.
As healthcare organizations saw before the COVID-19 pandemic and are feeling more sharply now, “nurses and other clinicians become scarce when they don’t feel valued,” says Terrence R. McWilliams, MD, FAAFP, director and chief clinical consultant with HSG Advisors, Louisville, Ky. For this reason, “we need to utilize all our support staff at the top of their capabilities to allow our clinicians to practice at the top of theirs.”
The professional fulfillment that goes hand in hand with a top-of-license environment can bolster an organization’s ability to hire and keep the best people and possibly slow the exit of clinicians from the profession, McWilliams contends.
Indeed, a growing body of evidence links top-of-license practice with job satisfaction and, by extension, recruitment and retention success. The data also show a connection between a top-of-license environment and improvements in patient care and patient satisfaction and financial performance.
More organizations are experiencing the profound financial impact of losing nurses. According to the 2022 Nursing Solutions Inc. National Healthcare Staffing and Retention Report, the turnover rate for staff nurses increased 8.4% in 2021 to an average of 27.1%, while the average cost of turnover for one staff nurse rose 15% from $40,038 in 2020 to $46,100 in 2021.
An Urgent Need for Change
Of course, creating a top-of-license environment that reduces turnover is neither simple nor straightforward.
“It’s not an easy climb, because so many nonnursing tasks befall nurses, and those tasks are harder to bucketize than people think,” says Barbara Anspach, RN, FACHE, a Dallas-based consultant.
But in a post-COVID-19 world, taking steps to develop a more rewarding workplace has assumed new urgency. Today, as providers scramble to recruit and retain talent, the need has never been greater to stand out from the competition.
Evidence for that comes from a 2022 survey of 1,500 nurses by Nurse.org, which found that only 12% of nurses are happy in their current job.
According to Anspach, professional organizations understand the seriousness of this unhappiness, and they realize that the sector has no choice but to make professional fulfillment and other workplace changes for clinicians a national priority.
At the local level, in the wake of the “great resignation” by nurses and other healthcare workers from their positions during the pandemic, an organization’s ability to care for its caregivers by meeting demands around work-life balance, scheduling flexibility and top-of-license practice is no longer a frill, it’s a prerequisite, Anspach argues.
“The nursing shortage requires providers to make smarter use of the nurses they do have, which means enabling them to do the things they went to school for and to minimize time spent on nonnursing responsibilities,” she says.
The American Organization for Nursing Leadership’s 2022 Nursing Leadership Workforce Compendium of workplace best practices recommends, among other things, looking for opportunities to offload time-consuming tasks for nurse leaders such as staffing and scheduling, and reducing requirements for nurse manager attendance at meetings. “Be willing to take small bets versus waiting for evidence or research to support new initiatives,” AONL urges.
McWilliams advises organizations embarking on top-of-license initiatives to begin by knowing that the transformation will require time and a long-term plan. He stresses the importance of involving all stakeholders in developing a vision for how their roles will change and piloting strategies before rolling them out.
As with so many other kinds of healthcare change, success hinges on a shared commitment by clinical and nonclinical leaders and requires adequate dedicated support from IT, human resources and elsewhere, McWilliams says.
Workplace improvement programs for clinicians, including top-of-license initiatives, have captured the attention of entire C-suites because labor costs have begun outstripping supply costs, notes Anspach.
That means staffing issues are no longer being handled solely by the CNO or COO. The financial wallop of turnover has elicited a commitment to recruitment and retention from the whole executive team.
That includes participation by the CMO in developing efforts that demonstrate that the organization is a place where clinicians can develop their careers and find professional fulfillment.
Anspach advises organizations to pair researching what others have done and what has succeeded or failed with listening closely to their own staff. She advocates a multipronged approach that solicits input from all employee groups that touch patients. “You can’t get clinicians practicing at the top of their license if you don’t have people to take those offloaded duties, but first you need to find out what duties most detract from the ability to work at top of license in each setting,” she says.
Though strategic discussions are necessary, Anspach says, so are action steps and deadlines. “Initiatives fall apart without clear lines of accountability. That’s why the executive team needs to be driving this.”
Following are profiles of three providers striving to create a top-of-license milieu and a workplace where clinicians can find meaning and joy.
Virginia Mason Franciscan Health: Partnerships Bolster Nurse Expertise
Virginia Mason Franciscan Health sees the upheaval wrought by the pandemic as a fresh opportunity to partner with care team members in developing top-of-license care across the system’s 10 hospitals and nearly 300 care sites in Washington’s Puget Sound region.
“We’ve always had worker shortages, but this time, the changes aren’t cyclical, so past models will no longer sustain us,” says Dianne Aroh, RN, FACHE, senior vice president and CNO.
The 1,500-bed system is crafting care models that will give the organization its first road map for top-of-license care. “We’ve had discussions about it but never pinned down what it would look like,” she says. “Now, we’re scrutinizing everything a nurse does to find ways to help them practice at top of license. That’s a silver lining.”
Recognizing the value of LPNs as a resource across settings, and to create a pipeline of future nurses, the system has partnered with community schools throughout the region to reinstate their LPN programs. It recruits LPN graduates for positions in acute care, where they relieve RNs of admission, discharge and transfer responsibilities. Educational sponsorships to become RNs offer incentives to keep the LPNs in the profession and at Virginia Mason.
That shifting of responsibilities “frees our nurses to perform more of the tasks that only RNs can do,” says Aroh. “The more we can ease the burden of work on the nurses, the more they can work at the top of their license and partner effectively with our physicians.”
In similar role-shifting initiatives, the system is hiring safety companions for patients who present to the ED with suicidal ideation; partnering with pharmacy technicians to perform medication reconciliations; and deploying medical assistants across settings to relieve RNs of a variety of non-RN-required tasks.
Other initiatives include the system’s first home care recovery program, launched in January at St. Joseph Medical Center in Tacoma, Wash., for patients with COPD, pneumonia and other acute conditions. Patients who choose this option are remotely monitored and receive on-site nursing visits and virtual visits with their physicians.
The program’s expected efficiencies and quality improvements, including reduced length of stay and increased inpatient capacity, will support top-of-license practice for nurses as well, says Aroh.
In April 2023, the organization launched an enhanced care nursing team at its first pilot facility, St. Anthony Hospital. This program integrates a virtually enhanced team of nurses as members of the inpatient care team. These nurses handle admissions, discharges, transfers and follow-up calls to patients and physicians.
In addition to relieving front-line nurses of these and several other tasks, the program gives experienced nurses, including those nearing retirement, an attractive remote work option while allowing the system to continue benefiting from their knowledge and expertise.
These seasoned clinicians offer valuable support, especially for first-year, front-line nurses, the group at highest risk of turnover, Aroh notes.
Though the harsh realities of post-pandemic staffing shortages are not going to disappear, “they’re an opportunity to get creative,” says Aroh. She advises organizations to “lean into what your care team members are saying, be open to new models and ideas, and never underestimate the power of leading with kindness and imagining yourself in your nurses’ shoes.”
Parkland Health: A ‘One Parkland’ Mindset to Develop Top Performers
One of the country’s largest public health systems, Parkland Health, Dallas, also views the current post-pandemic staffing shortage as a transformation opportunity. At the heart of that transformation is the system’s willingness to prioritize the professional development goals of clinicians over a given department’s desire to keep top-performing individuals where they are.
“Using APPs at this level improves efficiency and allows our physicians to see more new patients.”
“We’ve taken the unfortunate staffing circumstances of the post-COVID period and rebranded ourselves as an organization that reengages and reinvests in our most talented people rather than focusing solely on the market,” says DeLancey Johnson, DBA, senior vice president and associate chief talent officer, and an ACHE Member.
“When people have joy at work, they have the tendency to stay. To establish that joy, we need to find ways to help them practice at the top of their license,” says Johnson.
At Parkland, the desire to foster that joy in a top-of-license milieu manifests in an emphasis on the “upskilling” and “reskilling” of top staff to support their professional mobility within the system. Examples include educational sponsorship programs for certified nursing assistants interested in becoming RNs and for advanced practice providers interested in building new areas of expertise.
Rallying clinical leaders to live and breathe this new mindset is a work in progress, Johnson says. But they’re quickly learning that traditional thinking no longer holds water with today’s workforce. Gone are the days when a leader could expect a top performer to stay in the same job for 20 years.
They’re also learning that top-of-license practice won’t happen without a leadership style that emphasizes professional fulfillment for their teams, including opportunities that might even help individuals move elsewhere within the system.
“We’re challenging clinical leaders to provide the tools to our top performers to grow at Parkland, whether it’s horizontally or vertically, so that we can keep our best people,” says Johnson. “The thinking is ‘one Parkland’ versus ‘your department.’ We all need to be wearing the same jersey, if you will.”
To build buy-in and a sense of shared responsibility among clinical leaders across the continuum, Johnson and his colleagues dove deeply into Parkland Health’s recruitment and retention data to build a compelling business case for top-of-license care. That data demonstrated, among other things, that clinicians who leave the organization tend to do so because of dissatisfaction with their scope of responsibilities.
“We used the data to build a ‘burning bridge’ that will transform the way leaders think about their staff and keep them from sliding back into traditional leadership approaches that no longer serve us well,” he says.
Other top-of-license initiatives at Parkland include ongoing work by the nursing informatics team to weed out redundancy to reduce administrative burden, and the extensive use of advanced practice providers at the system’s network of community clinics.
Under the direction of physicians, “these providers facilitate and manage health outcomes at the top level,” says Johnson. These opportunities to lead clinical outcomes help the system stand out in the marketplace.
West Virginia University Hospitals: An Advocate for APPs
Like Parkland Health, the West Virginia University Health System, Morgantown, also employs a sizeable cadre of advanced practice providers who function largely autonomously (with appropriate physician supervision). These clinicians primarily see return patients at the system’s five-state network of outpatient clinics.
“Using APPs at this level improves efficiency and allows our physicians to see more new patients,” says Michael A. Grace, EdD, FACHE, chief administrative officer of the health system and president of WVU’s four hospitals. That also translates into enhanced revenue, more volume and more market share.
The system’s extensive use of APPs is an aspect of the organization’s efforts to build a positive, rewarding environment for clinicians that’s been working exceptionally well, according to Grace.
The organization, which improved its overall retention rate by 4% in 2022, lowered the vacancy rate to 11% and recently added 1,000 full-time employees, bringing the total staff to 10,500, offers a challenging and varied practice environment that APPs find appealing. APP turnover hovered at 7% in 2022.
Grace attributes the WVU Health System’s ability to recruit and retain qualified providers in part to its dedicated support structures for APPs, which include a senior council with APP representation that serves as an advisory committee to the system’s practice plan board of directors. The framework also includes a director of advanced practice providers whose job is to advocate for the APPs and ensure that they continue practicing to the highest extent of their training and education.
The director reviews all requests for new or replacement positions and works with requesting clinical departments to make sure that the APPs who fill the position will be working at the top of their license. Though pockets of dissatisfaction around top-of-license issues occasionally spring up, “having a leader dedicated solely to the interests of the APPs who serves as their voice and monitors their utilization throughout the organization has gone a long way toward ensuring a rewarding environment that boosts satisfaction and supports retention,” says Grace.
The director has the authority to approve or deny the requested position based on the department’s plans for how the APP will be used. For example, if the rationale for hiring one is to relieve a physician of documentation responsibilities, “we will hire that physician a medical scribe, not an APP,” says Grace.
“Without that administrative layer in place advocating specifically for the interests of our APPs, it would be very easy for clinicians to fall into positions in which they’re not putting their hard-earned training and education to good use,” he says. “That leads to turnover.”
When it comes to recruitment, Grace is a big believer in the power of word of mouth. “What works is when your people go back to their friends and families and say that WVU Hospitals is a great place to work. What doesn’t work is billboards and social media ads.”
As organizations continue to grapple with lingering staffing shortages intensified by the pandemic, their ability to devise systems and strategies around top-of-license practice will enhance their reputations as employers and give them a competitive edge. That’s never been more important than now.
Susan Birk is a Chicago-based freelance writer specializing in healthcare.