The cardiothoracic ICU at South Shore University Hospital, in Bay Shore, New York, found that adding a swing-shift RN position was associated with a reduction in nurse turnover from 8.3% to 2.7% in less than two years. The new role provides workload support by ensuring break coverage for other RNs and assisting with patient transfers and admissions.
This position was developed as a project through South Shore's participation in AACN Clinical Scene Investigator (CSI) Academy. The CSI program is designed to empower nurses with the knowledge and skills to create lasting change that optimizes quality indicators and improves the health of their work environment.
The Challenge
The unit focused its project on healthy work environments and initially explored staff burnout as the primary concern. They started by conducting a burnout-focused survey, but the results weren't as definitive as they had anticipated.
"We thought our issue was burnout, but then we figured out that it wasn't," said Kendra Dunn, a member of South Shore's CSI team. "So after discussing our findings with AACN's CSI Academy staff, they suggested we conduct a healthy work environment survey, and this was a turning point for us. The survey results revealed that our work environment had areas in need of improvement, particularly around appropriate staffing and meaningful recognition for the staff."
Recognizing these focus areas helped the team refine its project and lay the foundation to implement change.
A New Idea
The unit decided to trial a new swing-shift RN position, and they launched a three-month pilot program to assess the role's impact before making it permanent. During the pilot program, nurses interested in the swing-shift position worked in the role to experience and demonstrate how it would work. Key stakeholders included the nurses, surgeons, providers and even the patients on the unit who provided feedback after each trial period on how the role could benefit the unit and its function.
The unit's nurse manager and director also met with the local nurse union representative to outline the anticipated benefits and overview for the pilot program. Adding the swing-shift position meant closing an open position from another shift, so collaboration with the union was essential.
"Our intent when we did this pilot program was to allow all the CTICU employees the opportunity to participate, ensuring that we were fair and inclusive," said Francesca McKeown, assistant nurse manager. "Throughout the whole process, the unit was very supportive. They recognized the potential advantages for the unit – not only for the nurses, but for the patients as well. And the results of the pilot showed the role indeed had a positive impact."
Implementation
Following the successful pilot program, unit managers converted an open full-time night position into the new swing-shift position. As a result, they didn't need to add any full-time or part-time positions, which made the role easier to approve. Dunn was hired as the first nurse in the swing-shift position.
On a typical day, Dunn arrives at 11 a.m., and the first open-heart cases leave the operating room around 11:30 a.m. This gives her time to assess the unit, see which of her colleagues has a procedure, a transfer or a discharge and to complete any needed unit tasks - such as checking the code card and taking the PIXIS count. She also checks the status of patients' profiles, which require completion within 24 hours of admissions. Dunn also plans break coverage for the dayshift and helps with off-unit tests, such as taking a patient to CT scan.
As patients start coming out of the operating room, Dunn prioritizes their admissions. She said, "Typically when we have an open heart case, you need at least two nurses in the room. As you can imagine, there is a lot going on, connecting chest tubes and drips, etc. I can be their assist in that."
Dunn's CSI teammate Allison Zentgraf noted, "We're only a 10-bed unit. So there are days that we have four cases. That means we have 10 patients and we have to figure out who we're moving, get them down to the floor, clean the room and then get the room set up for the open heart case. So, there's a lot of movement first thing in the morning. When Kendra comes in, usually we'll be able to do breaks and she'll be able to relieve us a little bit, even for just a morning break. It's really helpful."
Implementing the swing-shift role was positively received by nurses and also by other members of the hospital staff. Dunn noted that to ensure rooms are ready for new admissions, she partners with environmental services.
Measures of Success
Since implementation of this role, the project team says nurses are able to confidently take full, uninterrupted lunch breaks. Nurses also provided survey feedback that they are able to complete their charting in a more timely manner and feel less behind with their work.
"When we compared the turnover rate, it dropped to 2.7% after we implemented this role," McKeown said. "So we're still fully staffed; all our positions, FTEs and part-times, are still intact. I think we received a lot of positive feedback from the nurses saying they feel like there's a shift on the unit for the better."
Managers hope to approve an additional part-time swing-shift position, which would provide support five days a week.
"What we're hoping for, because this has been so well received and has been so positive for our unit, is to convert my position 11 to 9, into three 11 to 11s and then also have a part-time position 11 to 11, so there's coverage five days a week," Dunn said. "So every day that they're operating, there is somebody here for a swing shift to assist."
Lessons Learned
By having a dedicated RN position to cover new admissions or transitional needs, other nurses on the unit are able to continue focusing on their patients and current assignments.
"Having an actual position that's able to help and make those changes and not having a nurse pulled to a different unit makes it so much easier. It's just an overall better vibe on the unit," Zentgraf said. "Honestly, we really thought it was a burnout issue, when in fact it was a negative work vibe. It was a real relief when we were able to finally identify it and come up with a solution."
One of the challenges the group described in creating a brand-new role was identifying the competencies it required. Through staff feedback, they learned that the swing-shift nurse needed to be experienced, collaborative, proactive in identifying the support that was needed, and able to maintain a good rapport with other staff.
"We would like to thank our CTICU team, our amazing nurses, providers and ancillary staff for their patience, support, involvement and encouragement throughout this project. The success of this project wouldn't have been possible without all of them," McKeown added.
Advice to Nurses
For a team thinking about creating a similar position, the South Shore project team encourages holding events frequently to keep the staff engaged and involved.
"The staff's engagement and the interest in the role is what we really feel made management and the union see clearly that this role was so necessary," Dunn said. "We held parties in the break room. We had taco night. And while we did that, we presented to them and kept them engaged with our project.
"I would encourage as much feedback from the staff as possible. I think that we were so successful in the project, because we had that open communication with the staff and we were transparent throughout the whole process."
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