Investing in our human capital: Sharing the experience of implementing a retention strategy at a large academic hospital from a leadership lens.

The impact of the COVID-19 pandemic on healthcare providers is well documented and has resulted in significant pressures from a health human resources perspective with many point-of-care providers taking extended leave or moreover, leaving the healthcare sector altogether. As part of a larger Health Human Resources (HHR) strategy at Sunnybrook Health Sciences Centre (Sunnybrook) in Toronto, Canada, a time-limited interprofessional working group titled Supporting Team Sunnybrook (STS) was created. The working group was created to focus on staff retention to respond to ongoing concerns by leaders with regard to staff leaving the organization at an increased rate as documented by our organization's decision support team. Anecdotally, many staff cited their decision to leave the organization as a consequence of the pandemic. As no staff retention committee had been formally created at our organization, STS was established to engage all staff members while addressing and resolving current feedback, concerns, suggestions and issues. The objective of our working group was to review published literature, establish themes from this review, and align these themes to priority themes brought forward by staff through a number of data capture activities. Data capture activities included reviewing existing survey data, new survey data and meetings with staff members. Analysis of the data resulted in the identification of five key consensus areas (priority themes): Staff recognition, wellbeing, grow at Sunnybrook, leaderful leaders, and communication. Our team created five corresponding working groups with the aim to create short- and long-term goals, as well as time sensitive and sustainable operational activities that would contribute to improved staff retention at our organization. Outcomes from our work provided two key learnings to leaders on their ongoing work to retain staff which were the importance of: (1) engagement across all roles, professions including non-clinical team members and support staff and (2) broad communication on the outcomes of our working group to demonstrate that that their feedback was taken seriously and acted upon.

Background and context

The impact of the COVID-19 pandemic on healthcare providers is well documented and has resulted in significant pressures from a health human resources perspective. The published literature provides powerful insight into the resulting impact of the pandemic on point-of-care health care providers, particularly on their well-being, which is defined as their psychological and mental health [1]. Moreover, staff well-being relates to the downstream retention impact of the healthcare workforce [2,3], resulting in healthcare providers leaving the profession at an increased rate. As part of a larger Health Human Resources (HHR) strategy at Sunnybrook, a time-limited working group was created titled Supporting Team Sunnybrook (STS), to focus on maintaining the current functioning workforce. The working group was created to focus on staff retention to respond to ongoing concerns by leaders with regard to staff leaving the organization at an increased rate, as documented by our organization's decision support team. The STS goal was implemented with the aim of engaging current staff in creating retention strategies to inform an operational work plan that could immediately address workforce pressures.

Retention literature focuses primarily on nurses [4], but in our work at Sunnybrook, our aim was to focus our initiative on all team members and professions, in both clinical and non-clinical roles. Phillips et al. [5] indicate that having adequate access to resources, proper leadership training, and sufficient staffing levels are all beneficial to retaining staff at healthcare organizations. Zaheer et al. [6] state that positive workplace connections, strong team building, and autonomy all contribute to staff retention. Autonomy refers to less controlled motivation and more independent (self-directed) motivation, with the latter aligning with personal values as well as occupational and personal commitment [7]. In addition, work-life balance, educational assistance and aids, and financial incentives are integral to retention strategies within organizations [8].

The core value of STS was based on the ‘Wisdom of Crowds’ [9]. This belief highlights the importance of leadership and bringing together the ideas and concepts from a variety of individuals across Team Sunnybrook, hence our decision to engage as many staff members as possible as part of our data capture activities. Having input from all team members provided STS with the opportunity to explore a wide range of perspectives, insight and feedback. The inclusion of diverse perspectives was fundamental to the methodology chosen, as each Sunnybrook team member has a different story to share as well as unique values that are important to them. Finally, the initiative was driven by a number of agreed-upon principles that that core team discussed as important to them to guide our work together. These principles included confidentiality, transparency, open communication, inclusion, acting and always looping back; these principles guided all decision making.

Supporting Team Sunnybrook had a number of pre-determined goals. These goals determined the purpose and strategy behind STS as well as the process used to inform our data gathering process. The goals included: 1. capturing qualitative and quantitative internal and external existing data; 2. reviewing the published literature on staff retention in health care; and 3. creating with key stakeholders an action plan that was inclusive of Team Sunnybrook, including learners and non-clinical roles. The goals would culminate in creating an operational short-term and long-term work plan that linked to Sunnybrook's Workforce Optimization Framework (WOF) (Fig. 1 ).

Fig. 1

Sunnybrook's workforce optimization framework titled building team sunnybrook ©2022.

The aim of this paper is to share the experience of our team, as well as our learning reflections on this initiative through a leadership lens. These learnings can be generalized to all health professional roles across the healthcare system both locally and more broadly.

Process

Institutional ethics review was not required for this project as determined by the Sunnybrook Health Sciences Ethics Review Self-Assessment Tool (ER-SAT) and confirmed with the Ethics Office.

Project team

The project team consisted of a core team as well as a larger STS team. The small, focused core team included a number of leaders who varied in their roles and experience, including leaders from nursing, allied health, organizational development and human resources. The core team was voluntarily recruited through an invitation to the members of our leaders’ forum. The leaders’ forum is held monthly to connect all leaders (for example, professional leaders, managers and directors) across the organization. The core team was asked to lead the initiative as part of their contribution to the larger HHR strategy. The core team was responsible for generating a scope of work, foundational activities, organization and taking leadership on multiple “working groups”. Each member within the core STS team volunteered to lead or co-lead one of the five working groups (staff recognition, wellbeing, grow at Sunnybrook, leaderful leaders, and communication), in which each investigated and assembled ideas and corresponding strategies to improve staff retention at Sunnybrook. The core team members communicated the progress through weekly virtual meetings, which allowed for further team input, suggestions, and unique perspectives.

Alongside the core team, there was a complimentary larger group of Sunnybrook team members. The larger team was voluntarily recruited from across the organization through an invitation posted on our internal organization's website. The larger team was involved in key milestone activities, including participating in Discovery Week and ensuring that the action plan resonated with what was heard across the organization among their peers and colleagues.

The diversity presented within both groups was a remarkable asset [10], as each member brought a unique perspective and ability to connect within the larger Team Sunnybrook community. Sunnybrook is an expansive health care facility within Toronto, Ontario, Canada, with over 10,000 staff members across multiple campuses, making networking, diversity and inclusion a key component of STS. The ability to discuss retention with a wide range of Sunnybrook staff members was pivotal as part of the data collection process, specifically during discovery activities.

Data sources

A multi-pronged approach was used to inform the work consisting of two data sources: existing and new data.

When exploring existing data, informal exit interviews and published literature from the Canadian and international healthcare sectors were reviewed. These conversational exit interviews were conducted by managers or professional leaders when a staff member was leaving the organization. A literature review was conducted by the project team using key search terms related to health human resources and retention using published databases. In addition, generalized themes from the organizational engagement survey were shared with the team. The engagement survey was an online survey sent across the entire organization, focusing on the experience of what it is like to work at and be a part of Team Sunnybrook. A variety of topics were explored, such as staff stress levels, the significance of collaboration, and areas the organization can improve upon in order to support its team members. The existing data was voluntarily shared with the project team from human resources as well as from leaders, managers and directors at our organization.

Discovery Week was a period of time designated for the Supporting Team Sunnybrook (STS) members to facilitate informal conversations with their peers and colleagues. The aim was to understand the staff's experience of working at Sunnybrook, their perceptions of staff well-being, and gather ideas for how to make an impactful difference for staff wellbeing, recognition, and retention. Each member of the STS team, of both the core and larger group, was asked to facilitate a conversation with at least five peers and colleagues to receive their input. Four key questions guided the conversation, which were “What do you like about your role at Sunnybrook?”, “What makes you consider leaving your role at Sunnybrook?”, “What can we change immediately and in the long term?” and “On the recent engagement survey, the teams identified they want recognition. What does recognition look like for you?” The four key questions were determined by the larger group in one of the earlier brainstorming meetings when deciding what information would be important to create an operational plan. When facilitating these conversations, the STS team members conducting the conversation were asked to prompt their colleague for specific details within each of their narratives so that ideas included specific activities that could inform a work plan.

Data analysis

Data were analysed using thematic analysis, which is appropriate for introductory studies [11]. The responses were independently reviewed and analyzed by two team members, which began with in-depth reading of all the responses received during Discovery Week. This was followed by the two members manually coding and grouping codes into priority themes with related activities. The core team met to review the identified priority themes linked to accompanying activities. The findings were discussed in detail to achieve consensus. This was followed a prioritization exercise. This exercise reviewed each ideated within each priority theme to determine which should be prioritized based on an impact-effort matrix exercise [12]. For example, which activities we could complete right away, essentially termed ‘low hanging fruit’ versus activities that might take a longer time to accomplish and require increased resources beyond the scope of this project.

The data gathered from both existing and new data sources were shared with the larger STS team. The members of the larger STS team were asked if the data captured resonated with what they heard and observed throughout the organization, including contextual information.

Scope, strategies and outcomes

Published literature from both the Canadian and international healthcare sectors identified key themes. These included autonomy, equity, mentorships, relationships, support system, strong leadership, diversity, and culture, as well as career and educational development [5,6,8].

Data from the engagement survey uncovered the overall strengths and areas of improvement of Sunnybrook as an employer. Respondents indicated that they were proud to work at the organization and would apply here again; however, they did indicate that workload was heavy.

Data from the informal exit interviews aligned similarly to findings from the engagement survey. However, other themes captured included the desire for more flexibility in scheduling as well as more opportunities for professional development.

Creating new data collection methods was a pivotal component of the process in order to attain the current perspective of our team members. These new data collection strategies included broad engagement through email awareness and unit huddles, focused engagement by peers and colleagues from the larger STS team, practice council collaboration, leader engagement, and a planned Discovery Week. It was integral to engage as many team members as possible to ensure that our outcomes represented a unified strategy representative of all voices at our organization. Over 250 responses were received during Discovery Week. The responses represented all roles, departments and campuses across the organization. The responses were collated and bucketed into priority themes. Five priority themes were identified that resulted in five corresponding working groups, with the fifth (communication) established to enable the original four priority themes. The five priority themes were: staff recognition, wellbeing, grow at Sunnybrook, leaderful leaders and communication (Table 1 ).

Table 1

Five priority themes identified.

Priority Theme	Quote
Priority theme 1: Staff Recognition	“Sometimes the small things make a big difference. For example, useful giveaway things like a good quality pen, sticky notes, and badge protectors.”
Priority theme 2: Wellbeing	“Other opportunities for mental health support given that we cannot change our current benefits”“Create a mental health library and increase resources”
Priority theme 3: Grow at Sunnybrook	“The ability for self-advancement”“Support staff to grow and expand career”
Priority theme 4: Leaderful Leaders	“Encourage leadership to foster their creativity”“Encourage change, new ideas and a learner mindset. Be passionate about what you do. Advertise what kind of education the hospital is looking for (specific courses that are useful for a certain profession … Make more education happen on site. Mentor/train those with management potential.”
Priority theme 5: Communication	“Staff become more pessimistic when things change. If management doesn't show how they have tried to change things then staff don't speak up the next time because they know the results. When we explain what the working group is about we've noticed a response of incredulity; things will not change from many we've talked to.”“Many surveys … Is anything going to come from this? What's the point?”

Priority theme 1: staff recognition

Recognition and acknowledging Team Sunnybrook's dedication and commitment was one of the fundamental components of Supporting Team Sunnybrook. This led to the creation of a working group directly focused on the development of strategies for improving recognition across the organization that could be leveraged by leaders, both formal and informal.

Prior to creating strategies for staff recognition, the members of the working group explored existing initiatives for recognition across the organization and discussed the feasibility, effectiveness, and inclusiveness of both existing and potential strategies. One key feature for the creation of new recognition strategies was ensuring that the recognition was both meaningful and equitable to all staff. While gathering information, it became apparent that staff felt recognition can quickly evolve into a contest of popularity rather than merely recognizing individuals for hard work and dedication. This concern was at the forefront of the working group's discussions and was also prevalent when analyzing the new data found during Discovery Week.

The team was inspired to create a staff recognition toolkit. The goal was to assemble a variety of accessible resources, which managers could use to recognize their staff member's dedication and efforts on a regular basis. The working group created a staff recognition toolkit, which was shared with the Human Resources (HR) Team to be integrated with future recognition initiatives. Some of the resources included in the toolkit were newly developed thank-you and recognition cards, sharing motivational quotes, and unit recognition boards. The working group developed a vision of providing each manager in the organization with a basket that included these resources. Since meaningful recognition was at the forefront of the working group's discussion, initiatives such as encouraging managers to meet with each team member and providing staff with regular performance reviews were also shared with HR as a part of a potential staff recognition toolkit.

Alongside the initiatives presented within the staff recognition toolkit, the working group prototyped a poster, which was a visual representation of how managers can show appreciation and recognition of their staff. The poster included a variety of ways to recognize staff, and detailed the importance of continued recognition within the workplace.

Priority theme 2: wellbeing

Team Sunnybrook's well-being was identified as a priority by leaders as well as respondents when strategizing how best to improve retention among staff. The STS wellbeing working group, in communication with Sunnybrook's already existing corporate wellness team, developed initiatives aimed to support the physical and mental well-being of staff.

Together, both groups created and facilitated several strategies to improve staff members’ well-being. Three initiatives were immediately implemented with an overwhelmingly positive response. One of the largest projects was enhancing staff lounges throughout the organization. The lounge spaces are locations where staff take breaks, and many of which have been well used throughout the years. Providing staff with uplifted lounge spaces can improve their overall workspace, which in turn may improve mental and physical wellbeing to rejuvenate them (during their shift) as they return to the care of their patients.

The wellbeing working group collaborated with the Sunnybrook Creative Art Therapies (CAT) department to establish two arts-based initiatives, “Art Breaks” and team Spotify playlists. Art breaks were an initiative that provided Sunnybrook clinical units with unique colouring books and markers that were created by the CAT department. These books allowed units across Sunnybrook to colour together as a strategy to promote relaxation, encourage breaks from the challenges of the day, and provide opportunities to contribute to something as a team that could be displayed for everyone to see. Another unique initiative presented was the creation of team-specific playlists. Utilizing the Spotify platform, Sunnybrook Team members were able to submit songs that they find motivational or uplifting to create a team-specific playlist. The initiative prompted staff to reflect on their own meaningful music, share this music with the other members of their team, and then provided a team building opportunity as discussion about song choices was generated when playlists were shared with the teams. Completed playlists also served as an additional wellness resource that was specific to individual teams. Sunnybrook's senior leadership team also participated in the initiative and submitted songs to a playlist, which the entirety of team Sunnybrook had access to. As a complimentary activity, they invited staff members to guess which songs they selected.

The third initiative was the creation of a dance break initiative called SunnyMoves. This consisted of a small team of staff volunteers who traveled across the organization and encouraged staff members to join in a brief dance break at the local unit or work space. This uplifting group focused on the joy of dance and freedom of expression, harnessing laughter and music. Although the well-being of staff has always been a priority of Sunnybrook, the pandemic elevated and emphasized the importance of wellness as integral to retention strategies [13].

Priority theme 3: grow at sunnybrook

Grow at Sunnybrook comprised two priority areas of career pathways and professional development. This working group focused on improving personal and professional investment and growth. The aim was to encourage staff to stay at Sunnybrook and provide opportunities for career growth within the organization.

Ideas identified included understanding how Sunnybrook could support personal and professional development for its staff through a combination of current and new programming. The ideas brought forward focused on offering pragmatic opportunities to staff that focused on experiential placements, projects and career growth. For example, these included creating specialized career interest pathways, embedding a professional development goal setting exercise as part of onboarding, a formalized mentorship program, as well as creating secondment opportunities for staff to ‘try’ out other roles within the organization.

Evident from our discussions was that staff were unaware of the current robust offerings at Sunnybrook as part of our organizational development and leadership portfolio. As a result, a fifth working group was created to focus on communication, in particular to communicate the work of this initiative as well as to improve communication plans for all the themes that were identified.

Priority theme 4: leaderful leaders

The Leaderful Leaders working group aimed to impact how leaders throughout the organization lead their teams. The working group focused on integrating strategies to enhance leadership competencies and bringing awareness to existing developmental opportunities. This also included how leaders recognized and acknowledged the dedication and commitment of staff. Having a strong and supportive senior leadership team was identified as a fundamental component for ensuring Team Sunnybrook feels recognized and supported. These feelings of support contribute to overall staff wellbeing and retention. Respondents noted, “You join an organization but you leave a manager”.

During the initial planning phases of outlining and creating Team Sunnybrook's strategy, a variety of executable activities were uncovered. Some of these activities included; leader's having an open forum to listen to Team Sunnybrook's concerns, being more present throughout the hospital by completing “walk-arounds”, and providing education to leaders on authentic and value-based leadership approaches. The concept of team members having the opportunity to provide feedback to their own managers was also explored as an activity that could be implemented.

A major component of the Leaderful Leader's working group was ensuring that Sunnybrook leaders embody Raelin's four C's of leadership [14]. These four characteristics of leadership encourage leaders to be collaborative and encourage supportive leadership overall. Raelin's work describes collective leadership where every member can enter a leadership role and is not focused on one specific individual being labeled as a leader; concurrent leadership which highlights the concept that multiple team members are provided the opportunity to lead at the same time; collaborative leadership focuses on partnership within a team where all team members have; and all culminating to compassionate leadership, which ensures each member of the team is respected and their dignity is maintained in the decision making process. Using the four C's as a foundation for the Leaderful Leader's working group helped develop foundational strategies to ensure these leadership qualities are embodied throughout Team Sunnybrook, and highlighted in leadership development programs. At our organization, our Organizational Development and Leadership team provides a formalized curriculum that is available to our leaders whose topical content is based on these foundational concepts [15].

Priority theme 5: communication

Throughout all the data sources as well as all the discovery week discussions, respondents emphasized how important communication regarding this initiative was to enable the priority themes 1 through 4. In particular, respondents said they wanted to hear about the outcome of their ideas and feedback they provided regarding retention as they felt it was a gap across the organization. As a result, a communication plan was drafted that included broad communication using a number of forums to talk about actions taken on each activity and if no action was taken why that decision was made. The communication plan included email communication, posting on our internal website as well as discussion at our monthly leaders forum with a request for our leaders to include this discussion point as a standing agenda item at their recurring staff huddles and meetings.

Conclusion: Reflections and recommendations for leaders

Upon reflection, the core team inspired and promoted immediate change for staff wellbeing and retention at Sunnybrook. Prior to the creation of STS, Sunnybrook did not have a team dedicated to strategizing retention activities within the organization, which became increasingly necessary throughout the COVID-19 pandemic as the health human resources shortages impacted the broad system. Healthcare providers faced numerous challenges and were faced with unprecedented circumstances which ultimately affected their wellbeing and perspective on work-life as whole.

Our staff overwhelmingly engaged in this work across all roles, departments and campuses. The response to our Discovery Week was seen as a proxy of the need of staff to share their concerns as well as their ideas for retention. The immediate strategies STS implemented provided a positive direction and commitment to support our team members and let them know their voices have been heard. Outcomes from our work provided two key learnings to leaders on their ongoing work to retain staff which were the importance of: (1) engagement across all roles, professions including non-clinical team members and support staff and (2) broad communication on the outcomes of our working group to demonstrate that that their feedback was taken seriously and acted upon.

At the onset of this paper, STS was sunset, however the work was transitioned to the organization's Human Resources, Organizational Development and Leadership, and Wellness teams to continue and integrate activities identified by Team Sunnybrook as part of our sustainability plan. As part of the continued evaluation plan of this work, the Human Resources team will be implementing one question - “Would apply to work here again? - as part of a more frequent engagement survey to all staff as a proxy measure. Overall, a number of recommendations and learning were brought forward and shared with the leadership at Sunnybrook across a variety of domains from engagement through to communication (Box 1 ) as part of an addition to their leadership toolbox. Moreover, these learnings can be generalized to all healthcare leaders as we are faced with a complex healthcare environment that is integrated with health human shortages and a different philosophical perspective on work-life balance.

Box 1

Recommendations and learnings for our leaders.

• Engaging all staff to ensure a fulsome picture of needs, insight and perspectives represents our diverse and inclusive team

• Providing a wide range of resources and supports to support our leaders as there is no “one size fits all approach”

• Ensuring a communication plan across the entire team that includes all types of forums, for example, email, town hall, posters etc …

• Effecting change is facilitated by ensuring that a small core working group's initiatives are linked to a broader corporate strategy for sustained impact

• Communicating back, for example “closing the loop” on all staff engagement initiatives is the most important feature of maintaining staff's trust and commitment to the organization