Years later, memories of the conversation still hit Paula Agosto “like a punch in the gut.”
While attending the retirement party for a nurse who’d spent 40 years at the bedside, the guest of honor apologized to Agosto for being a disappointment—she’d never “climbed the ladder” to a higher nursing level or explored other roles in nursing.
“It hit me like a ton of bricks. Here was this woman who I consider to be a god in nursing, but we were clearly presenting a picture of success based on the structure in our professional development program,” says Agosto, senior vice president and chief nursing officer at Children’s Hospital of Philadelphia (CHOP). “That conversation made me realize this is wrong for the world of nursing and we should figure out some other way of doing this.”
Here are three changes Agosto made to meet nurses’ workplace needs in the new workforce landscape.
1. Turn ladders into lattices
“When it comes to creating a professional environment for growth, the one big takeaway we got from the staff is they want individual opportunity, individual respect and individual appreciation,” says Agosto.”
The traditional clinical “ladder” system of career advancement in nursing means any movement along the path not directly upward can be seen as a negative, and pursuing an advanced degree could affect one’s Clinical Nurse level.
CHOP replaced the ladder structure with the PEAK (Professional Excellence & Advancing Knowledge) model. It enables clinical nurses to pursue a variety of educational and professional development opportunities based on their individual goals and passions. Career summits can still be scaled, but nurses are also encouraged to accept new challenges at any level of the organization.
Interested participants approach a PEAK opportunity as they would any job opening—they submit a resume, draft a cover letter outlining their goals and navigate an interview process. PEAK assignments include compensation increases and funds for professional development expenses and training. Nurses can pursue further advancement opportunities across three levels of PEAK program assignments.
The workforce has embraced the program: nearly a quarter of the eligible workforce are enrolled in PEAK.
“We went from talking about ladders to lattices, and that gives voice to the notion that we value internal mobility,” says Joanne McCool, vice president of human resources. “People coming into the workforce now want mobility that can be up, down and across.”
2. Become more flexible
Since the pandemic, the organization embraces fluidity in its employee relationships—for example, allowing employees to toggle from full-time status to part time or per diem and vice versa.
“We continue to challenge ourselves on flexibility so that people can go through different seasons of their lives,” McCool says. “We want to help people find a role that is as well aligned as possible with the commitment they are willing and able to make at that time in their lives without breaking the relationship. While they're leaving the traditional employment model, they're declaring an interest in staying in a relationship with us and we're creating a mechanism to do that.”
This has required CHOP to make its operational structure more nimble, but it has enabled the hospital to meet the demands of the current workforce.
3. Empower staff
CHOP’s Shared Governance structure is a major driver of these changes. Today’s employees expect to have more input on their roles, and CHOP is leaning into that, according to McCool. Heavy investments in shared governance and two-way employee communications are paving the way for new ideas. That means more opportunities for staff—like an internal organizational gig economy—and a rethinking of not only what they can expect from their career but what they expect from their leaders.
“It's changing the job of the nurse manager from 80% functional expertise to a talent agent, a coach and a mentor," McCool says.
“You need to know who your players are, what their strengths are, how you are using them and if they need more training or some mentorship,” Agosto adds. “That's what I think leadership is now—you’re a coach/leader of your team more than anything else.”
Results: Reduced turnover rates
Turnover rates are the primary metric CHOP uses to gauge the effectiveness of shifts in its workforce paradigm.
- Overall turnover rates across all nursing jobs at CHOP fell from 11.4% in 2022 to 10.6% as of September 2023—a cost avoidance of at least $1 million.
- Despite a surge in new nurses since the pandemic, the turnover rate among first-year nurses has dropped two percentage points year-over-year.
- Turnover rates among outpatient nurses slid from 11.4% overall in 2021 to 8.7% in 2023, including a significant drop in the turnover rate of first-year outpatient nurses—from about 50% in 2021 to 12% in 2023.
While numerous factors contribute to these gains, it boils down to a rather simple concept. “We’re doing more listening,” Agosto says. “As many hospitals do, we use engagement surveys and take them very seriously, and more often than not, we make a change because we heard the staff asking for a change to be made.”