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High Levels of Agency Staff? Try These Five Steps for Team-Building

Teamwork is essential to providing high quality of care and quality of life to nursing home residents. However, it can be hard to establish between agency staff and permanent staff, points out Amy Franklin, RN, RAC-MTA, DNS-MT, QCP-MT, director of clinical services for American Baptist Homes of the Midwest (ABHM) in Eden Prairie, MN. “Sometimes, providers hear complaints that staff and some residents don’t trust agency personnel.”

There even can be a significant amount of anger toward agency staff, says Franklin. “Agency nurses come in earning $15 – $20 more an hour than your permanent staff. They’re also often more efficient simply because they are not caught up in the culture of the building and possibly holding onto a bad experience. As a result, staff nurses are often predisposed to dislike agency staff. And staff certified nursing assistants (CNAs) typically share a similar outlook.”

By their very nature, agency staff will never be full-fledged members of a nursing home’s work force. However, directors of nursing services (DNSs) can help agency staff work more cohesively with permanent staff by taking the following steps:

Don’t ignore uncomfortable divisions

Nurse managers should set the tone, says Franklin. “Agency staff are giving your permanent staff the opportunity to take a break—to not work 16-hour days and to be able to rotate out on vacation. You want your staff to treat the agency staff well, so try to establish the mindset that AAPACN founder Diane Carter advocated, which is ‘Circle the wagons and shoot outward, not inward.’ Staff need to understand that shooting inward—picking on agency staff—is the wrong approach. Everyone should celebrate that they are in your building and willing to help. This will help you develop the teamwork needed to provide the best care possible.”

Permanent staff having bias and concerns about agency staff is a longstanding problem throughout healthcare, adds Linda Winston, RN, MSN, BS, QCP-MT, DNS-MT, RAC-CT, a nurse consultant based in Norwich, NY. “There is research out there about many of these issues, such as the conversation about pay. You should look at both what the literature is telling you and what your work force is telling you so that you can come up with a strategy of response. For example, you can acknowledge that agency staff get more money while stressing the benefits that your permanent staff receive to help reduce that tension.”

Note: For more information about what can be found in the literature, see “In the Literature: Attitudes About Agency Staff” at the end of this article.

Ask dietary and housekeeping staff to step up

“Whether you use a formal communication process, such as the INTERACT Stop and Watch Early Warning Tool, or an informal process, you want staff outside of the nursing department who have a strong connection to the resident, such as dietary and housekeeping staff, to be involved in helping the nursing team identify potential problems, including significant changes in the resident’s condition,” says Franklin. “These are their residents too. If you ask them, they are willing to help agency staff who don’t know the residents well.”

For example, dietary staff can look out for residents in the dining room, telling agency staff that a particular resident needs to have their plate placed a certain way to prevent spills or making sure that another resident doesn’t get the wrong textured diet, preventing them from choking, says Franklin. “And housekeepers can identify that a resident doesn’t look the way they normally look. They don’t have the skills to deal with distress or stupor, but they can recognize those types of problems. They know when the resident isn’t right.”

DNSs also should make sure that dietary and housekeeping staff are introduced to new agency staff, says Franklin. “Turnover is so high in some buildings that even new permanent staff don’t always know other staff. Introductions will help the dietary and housekeeping staff be more comfortable providing insights about the residents.”

Weigh the costs vs. benefits of having agency staff attend team meetings

There may be staff meetings, such as Quality Assurance and Performance Improvement (QAPI) team meetings or clinical inservices, that agency staff need to be involved in, suggests Liz Wheeler, BSN, RN, CHPN, CDP, IPCO, a nurse consultant with LeaderStat in Powell, OH. “Especially if the majority of your staff shifts from permanent employees to agency, your systems may break down if agency staff aren’t attending key meetings so that they can be better incorporated into your team.”

Typically with agency staff, the expectation is that they get paid for the hours that they are there, so there could be some costs associated with having them come in extra hours for meetings or education, adds Wheeler. “You have look at the pros and cons. Do you want to pay a little extra to have an agency staff member come in for 30 – 60 minutes to ensure everyone is on the same page and working toward the same goals, or do you want to save that money? You need to set your expectations and then clearly communicate those expectations to the staffing agency to ensure that they are on board.”

Consider a staffing committee

A staffing committee may be another piece in solving the puzzle of how to help permanent staff work as a team with agency staff, says Winston. “Participants could include the DNS, the administrator, and other facility leadership (e.g., department heads that are committed to creating a culture of safe, competent, engaged staff); key supervisory staff; and informal leaders of the direct-care staff. In addition to forming the committee across levels, it’s a good idea to create it across departments because usually nursing staff aren’t the only ones who have problems with agency staff. For example, housekeeping and food services may also be having issues with them.”

Rather than having authority to make staffing decisions, the staffing committee may work best as an influencer, serving as a type of interdisciplinary QAPI team for staffing, suggests Winston. “Providers should support the efforts of direct-care staff to attend these meetings—and support them in being able to have their voices heard during the meeting. You want the participating direct-care staff to speak openly so that you hear what is happening on the floor. They can make sure that you know about concerns related to pay, related to agency staff not caring for residents in the same manner that is expected of the organization’s staff, or related to shift scheduling issues. For example, some facilities are allowing agency staff to pick and choose shifts, requiring permanent staff to take what’s left over.”

A staffing committee that meets routinely can be a component of the facility’s staffing strategy that helps build the culture of a safe staff, says Winston. “The committee can help you find solutions to staffing issues. Rather than worrying that ‘we don’t have enough staff,’ you can discuss issues, research solutions, implement solutions, and then follow solutions to see if they work. For example, the staffing committee may be able to help you work through a difficult holiday schedule.”

Making the staffing committee part of the solution helps permanent staff take ownership of what is happening, says Winston. “Committee members can help you problem solve and then take back information so that everyone understands that you are working in partnership with your permanent staff to deal with these ongoing staffing challenges as equitably as possible.”

Do longer contracts when possible

It can be difficult to build a team if new agency staff are coming in every two weeks, points out Winston. “You may not be able to do longer contracts to have the same nurse or the same CNA, but if you can plan ahead and the staffing agency is willing to work with you, contracts of three or more months with agency staff committed to work so many weekends and so many holidays can be beneficial in terms of stabilizing staff and giving them time to build relationships.”

From a resources standpoint, it also may be easier to devote time to agency staff who will be working for a longer time period (e.g., three to six months) than to keep repeating the same orientation and onboarding training for agency staff who work in the facility for shorter time periods, points out Wheeler. “You need to apply the same training to all agency staff and measure their understanding of that training—even if they are only with you for two weeks—so longer contracts could reduce your overall training workload.”

In the Literature: Attitudes About Agency Staff  
The Social Integration of Healthcare Agency Workers in Long-Term Care Facilities: A Cross-Sectional Study.” Lapalme MÈ, Doucet O. Int J Nurs Stud. 2018 Jun; 82:106-112. Epub 2018 Mar 17.
How Do I Stand Compared to Agency Workers? Justice Perceptions and Employees’ Counterproductive Work Behaviours.” Lapalme MÈ, Guerrero S. J Nurs Manag. 2019 Oct; 27(7):1471-1478. Epub 2019 Aug 14.
Us and Them: Experiences of Agency Nurses in Intensive Care Units.” Ronnie L. Intensive Crit Care Nurs. 2020 Feb; 56:102764. Epub 2019 Oct 23.
Work Relationships Between Agency and Permanent Staff.” Charnley D, Arnold J. Nurs Times. 2006 Aug 29-Sep 4;102(35):34-8.
Agency-Nursing Work: Perceptions and Experiences of Agency Nurses.” Manias E, Aitken R, Peerson A, Parker J, Wong K. Int J Nurs Stud. 2003 Mar; 40(3):269-79.

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