How Duke Health made strides in retaining nurses

Hospitals and health systems are facing a math problem, Theresa McDonnell says.

McDonnell, the chief nursing executive and senior vice president at Duke Health, says hospitals are caring for more patients, but they don’t expect a similar increase in clinicians.

“We've got far more demand and more patient need in a broader swath of geography than ever before, and we've got a shrinking workforce, and continuing to do things the way we've done them isn't going to solve the problem,” she says. “The only way we're really going to be able to keep up is to transform what care delivery looks like.”

McDonnell has been tackling that challenge at Duke Health since she joined the system in August 2023. Duke Health is using new technology and new strategies to bolster patient care and help the system’s nurses, she says.

The system is using virtual nursing, flexible scheduling, AI and other tools to improve the workplace for nurses, she told Chief Healthcare Executive® in a recent interview. Duke Health is also seeing better retention of its nurses and is relying on staffing agencies less to fill positions.

“When you feel like you're in more control, when you feel like you're not constantly being pulled and reacting, that decreases the anxiety, and at the end, it decreases burnout, and it increases our retention,” McDonnell says.

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Better scheduling and retention

Duke Health has implemented flexible scheduling for nursing staff, which has helped improve staffing and provides more options for nurses to work shifts of varying hours. Going beyond the 12-hour shifts commonly used in nurse scheduling, nurses can pick up shifts of eight hours, six hours, or even four hours.

The shorter shifts can offer more options for nurses who have kids at home, or for veteran nurses who are looking to continue to work but are finding a 12-hour shift less appealing.

“Rather than being fixed to a 12-hour shift, a nurse can pick up a gig four-hour shift so they can have far more flexibility to, again, manage all of the things they need to manage both inside the work environment and out,” McDonnell says.The flexible scheduling also includes giving nurses the opportunity to work some shifts in virtual nursing roles. Like some other health systems, Duke uses nurses to handle some tasks with patients virtually, including with admission or getting them ready to leave the hospital.

Some nurses can work in patient-facing roles on some days, and they can work virtually for some shifts.

“By leveraging virtual technology, we can beam that nurse in, and it serves a number of different purposes: better, more focused education with the patients and families for admissions, discharges, medications. But also that person can act as a mentor for a new nurse or a new grad, or someone who's maybe a little bit overwhelmed,” McDonnell says.

With more virtual nursing shifts available, Duke Health has helped retain longtime nurses who want to continue to care for patients but need less physically demanding roles.

“We've been able to retain quite a number of nurses who were at risk of retiring,” McDonnell says.

Those virtual shifts also can provide a way for some nurses who have work-related injuries to stay on the job, rather than go out on medical leave.

Over the past few years, Duke has reduced its use of staffing agencies to fill positions. McDonnell says when she came to Duke Health in 2023, the system had 800 travel nurses. Now, Duke Health has less than 100 travel nurses across the system.

The system’s turnover rate has also fallen, dropping from 24% in 2022 to around 15% now, she says.

Looking ahead, McDonnell says she sees changes in the ways nurses are trained, and she says training will likely include preparing for delivering care virtually.

“I don't think that the workforce is going to want to continue to be in one setting, and we need to give them that variability,” McDonnell says.

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AI aiding patients and staff

Duke Health is integrating more advanced analytics in the care setting, McDonnell says. The system has set up technology to monitor patients who may be at risk of falls in some rooms at Duke University Hospital. She says that can help avoid patient falls, which can lead to longer stays for patients.

“If the algorithm is picking up, sensing that a patient might be approaching a point where they might get out of bed and fall, that's an immediate notification to the nurse, and the nurse can go right in and intervene,” McDonnell says.

“We're going from reacting to pro-acting,” she says.

Duke Health has also utilized AI to create a “deterioration index” to help identify patients who may need more care.

“With advanced AI algorithms, large language modeling, we now have the ability to detect when a patient may be heading towards a deterioration to an event that could create a code or transfer to the ICU,” she says.

The care team will be notified and the patient can be moved to the intensive care unit before an acute episode takes place.

McDonnell says this offers obvious advantages for patients, but it also helps nurses and doctors by giving them more piece of mind. And those tools can also help reduce burnout among staff.

“When you talk about the things that really grind at people at the end of the day. It's fear, it's anxiety, it's that constant death by 1,000 cuts, things coming at you from every direction,” she says. “And when people feel most gratified in work is when they feel like they're on top of it. They've got it, they can manage the things in front of them. So these tools help with that.”

Even with some daunting math and other challenges, McDonnell says she remains optimistic about the ability to transform care and create a better work environment.

She also says the enthusiasm she sees in Duke Health’s nurses also gives her confidence in the future.

“We've got headwinds coming at us all around,” McDonnell says. “But never before have we been at a point in time where we've had so much opportunity and so much potential. We have the ability to transform the way we deliver care. We have the ability to think differently, but that also means unlocking a lot of the things that we have held on to historically.

“So if I'm not, if I can't be optimistic, then I need to switch careers. And what keeps me optimistic in this role is also I see that optimism in the workforce,” she says.