Shortages in the Nursing Workforce

Paul Anderson: Welcome to Smart Healthcare Safety from ECRI, the most trusted voice in healthcare, committed to advancing effective evidence- based care. I'm your host, Paul Anderson. And for more than 10 years, I've overseen our patient safety risk and quality membership programs here at ECRI. Tens of thousands of healthcare leaders rely on us as an independent, trusted authority to improve the safety, quality, and cost effectiveness of care across all healthcare settings worldwide. You can learn more about our unique capabilities to improve outcomes at www. ecri. org. Today we're taking another look at shortages in the nursing workforce. Healthcare has faced workforce shortages in the past. And even before the COVID 19 pandemic made things even worse, the American Nurses Association and the US Bureau of Labor statistics forecast the requirement of more than half a million registered nurses by 2022. Our guests are from the M. Louise Fitzpatrick College of Nursing at Villanova University located just outside of Philadelphia, Pennsylvania. Dr. Heather Brom is the Eastwood Family Endowed Assistant Professor of Nursing. And Donna Havens is the Connelly Endowed Dean and Professor of the M. Louise Fitzpatrick College of Nursing. So I mentioned as we get started that nursing shortages are nothing new. Workforce shortages in healthcare are nothing new. Donna Havens, how do we understand the current shortage in 2022, compared with shortages that we've seen in the past?

Donna Havens: So there have been shortages in the past. In fact, it's cyclical. You can count on it about every eight to 10 years or so. This one is different. Usually, there's a relationship between a shortage and organizations beginning to look at how they can save money and cut costs. And often they cut services that nurses depend on to deliver excellent care. And there's a, if you will, a lack of contentment about the practice environment in which the nurses are practicing when these things happen. Communication is involved. It's not as good. They may be pulled all over if you say a hospital where they don't normally work. And so there's some dissatisfaction. This time, the shortage has been compounded by a global pandemic in which not only were people desperate to find nurses to take care of patients. New York Times talked about two nurses taking care of 38 patients. They just became burned out. They became ill themselves. They took care of their colleagues who died while they were taking care of them. And they just... Burned out's not even the right word. They just became demoralized, tired, sick. Many had thought of retiring anyhow. And so they decided this is the time, but others who hadn't planned on retiring at this time decided maybe not to leave nursing, but to do something else within nursing that would be less stressful.

Heather Brom: Yeah, I would add to that and echo Donna's thoughts as well, but really thinking about even before the pandemic clinician wellbeing was a national concern. And we had high rates of nurses already experiencing burnout and contemplating kind of leaving their positions and then kind of facing the stressors of the pandemic, again, just compounding that. And that's also happening at a time where we have a kind of growing and aging population who's living longer with more chronic conditions and requiring care all across settings so not just in hospitals, but in primary care and specialty care as well. It is a perfect storm almost.

Paul Anderson: So as we're sitting here in the spring of 2022, pandemic looks like we're starting to get to a better place pretty consistently than we have been, let's say certainly over the winter and compared to the time before we had vaccines available and so on. So we're starting to move in the right direction with regard to the pandemic. Do we have a sense of what we think the scope of the shortage is going to be and the workforce capacity is going to be, as we start to get back to something that looks like normal?

Donna Havens: So we found at the M. Louise Fitzpatrick College of Nursing, that our applicants to enter our nursing programs increased substantially during all of this. But those are going to be young, inexperienced nurses that we're turning out into the workforce. I've talked to colleagues across the country, and many, many nursing schools found the same thing. People wanted to join the force, if you will, because of the pandemic. They realized also in my opinion, people for the first time really understood what nurses do and how very important they are. And they wanted to join up including people who hold degrees in another field decided they wanted to be nurses. So will that solve the problem? I don't know. Again, I'm saying there would be this input of inexperienced people that are going to need some time, and the organizations are going to have the capacity, need to have the capacity to educate them, to orient them, to onboard them, if you will, to gain a lot of the experience they maybe even missed during their education because of the pandemic.

Paul Anderson: Seems to me like the most direct way to add to the nursing workforce is to educate more nurses. Maybe that's a naive assessment though. Maybe there's more to it than that.

Heather Brom: Sure. I mean, I think it's a bit of like the pipeline and thinking about how we plan that. So it's what's the capacity within the colleges and schools of nursing to be able to have enough faculty to do the classes, how do we engage clinicians out in the hospitals and community settings to be preceptors? Right now it's a lot of it can be kind of ink in for some programs. So how do we draw more people in? And I also think about what all industries really have thought about how does work look different for their workers? And healthcare is no different. So I also think about one, capacity in terms of numbers but two, in terms of retention. So we're going to have an influx of excited and eager new nurses, but how do we also keep those experienced nurses at the bedside to mentor them and shepherd them along too?

Donna Havens: Yeah, yeah. Yeah. While people are applying to nursing schools, as Heather said, we don't have the capacity, not just us, schools across the nation don't have enough faculty to be able to accommodate them. If we had enough faculty, we don't have enough clinical settings to put them into, to educate them because the hospitals are short staffed in the clinics, et cetera. So it's a real total cycle that has to be addressed. It's a huge system that needs to be addressed.

Paul Anderson: So are there other things we can do then to try to bolster the workforce besides just turning out nurses as fast as we can? Are there other things we can do to try to ease the pain, so to speak?

Heather Brom: Well, another thing I think about is the decades of research about hospitals having better staffing equating to better patient outcomes and how can we get hospitals to the point where we can have that extra staff, that cushion of nurses rather than feeling it's kind of shift to shift how we're distributing nurses as well. So finding ways that increasing the supply of positions too could be one way to help improve work environments, decrease burnout for nurses, keeping them happy and satisfied in their roles, but ultimately leading to better patient outcomes too.

Donna Havens: Yeah. Heather's opened up an interesting topic, and that's how you organize nurses in their work settings. How you situate them so that they have the resources that they need to deliver the excellent care that they want to deliver. Do they have enough people to move patients from floor to floor? Do they have enough people to clean the rooms between patients? Often, and especially now, nurses end up doing all of that because there's no one else to do it. So it's how you organize them, how you provide supports, how you promote excellent communication between nurses, and nurses and others. All of that feeds into patient safety and quality care.

Paul Anderson: The phrase that keeps coming to mind is that idea of a total systems approach. It's yes, it's about the sheer number of nurses. That's really a critical input here, but it's far from being the only input here.

Donna Havens: Absolutely. It is a total system approach that's needed. And we know what to do. Heather mentioned research. Excuse me. We know what to do. We know the types of organization and systems that promote excellent outcomes. Can we put it back into place because in many cases it's all been dismantled during the pandemic.

Paul Anderson: And that's what I was going to ask then. So what are the barriers to getting from here to there? So what's sort of... Stipulate that of course, the pandemic itself is a barrier to lots of things. But are there other barriers that need to be addressed sort of at a systemic level or is it just a matter of just sheer willpower on the part of the provider organizations?

Heather Brom: Yeah, I think the former in terms of thinking about what can we do kind of systematically for bolstering nursing support in hospitals. Several states have tried for like what they would call kind of safe staffing ratios, but have really met resistance for that kind of state level legislation to occur. And a lot of it comes down to the cost and how we reimburse nursing care as well. Hospitals are primarily driven by the charges from the facilities and the physician, services that are provided. And is that kind of a piece of what's missing to be able to justify being able to hire more nurses and pay them well?

Donna Havens: Pay them what's appropriate and what's needed and what the market demands. Right now, many of the nurses have left the organizations to go work for travel agencies because they're making much more money. Well, if the organizations paid the nurses that they had in the first place, they wouldn't have all left. And now they're paying... One CEO told me recently, he's paying$ 15 million a month to bring in travel nurses. Now what if he took some of that money and paid his own nurses? They wouldn't be doing that.

Paul Anderson: Yeah, well, and clearly that travel model is not a sustainable solution for the organizations to staff their hospitals. It's an emergency measure, and it's not a long term solution clearly.

Donna Havens: No, no.

Paul Anderson: So with all that in mind, everything we've talked about, can you tell us a little bit about the CHAMPS study that was conducted there at Villanova? Can you tell us what that stands for and what were the goals and what did we find?

Donna Havens: So the CHAMPS study was developed at Villanova. We were, I think maybe the first and only nursing school at the time, back in May 2020, that decided it was really important to identify the emotional wellbeing and physical wellbeing of those who were in the field taking care of COVID patients. So we surveyed. We had no funding to do this. We piled, we put together what we could. We relied on nurses in the field, organizations, et cetera. And we collected important information about depression, anxiety, post traumatic stress syndrome, insomnia. And when we looked at just nurses, we didn't just survey nurses in the CHAMPS study. We looked at firemen, those who cleaned the rooms, et cetera, first responders, but we've analyzed the data fairly completely about nurses and published a few papers. And without a doubt, these people need assistance. They needed help. They were extremely high scoring on those measures of depression, anxiety, post traumatic stress. And it points to the need for organizations to do something to assist the emotional wellbeing of their staff. Heather, you were very active in this. Do you want to add to that?

Heather Brom: Yeah, I do. And what we did, and at the time kind of our comparison were international samples. And so part of the work that Don is talking about was really comparing our nurses levels of these wellbeing measures and finding that for depression, for example, our nurses were experiencing four times a level of depression as national, or excuse me, international samples during that time. Also with a sample at this time, we did some qualitative interviews and actually spoke to healthcare providers, again, primarily nurses. And especially during those early months of the pandemic, it really corroborated what we saw with that quantitative data in that they really voiced kind of similar themes of really lacking that their voices were being heard or that they were visible in their organization, not feeling a part of administration really being there to see them and really lacking some of the resources, whether it was staffing or especially at the early time, the personal protective equipment, and kind of relating that back to thinking about kind of work environments. Those are pillars of healthy, supportive work environments. And so these were nurses who were working in well respected hospital settings, but still really struggling to have their voices heard and all of their supports in place that they needed.

Donna Havens: One thing that really still troubles me when I think about it, one of our respondents told us that they went from heroes in the beginning or at the height of the pandemic to being zeros. They feel forgotten now. They'd go out and meet friends. No one was wearing masks, people weren't getting vaccinated. And it really took a toll on these folks who even with the levels of depression Heather mentioned, still got up every day and went back.

Paul Anderson: So one of the things I think about is that even before the pandemic, if we can think about the time before the pandemic, we had ECRI had been writing more and seeing more and hearing more about burnout concerns, about clinician wellbeing concerns across all sorts of different provider types. Did we learn anything from this CHAMPS study that it helps us sort of put some perspective on just how much worse COVID made it than it was say in 2019 or 2018?

Donna Havens: I actually think there are some important insights that we gained from this. And once again, it goes back to the resources nurses are given to deliver excellent care. It goes back to practice environment, the environment in which they're delivering care. And as I said, in many cases, excellent organizations had to do away with many of those supports and had to deconstruct the excellent work environment, if you will, simply to deliver care. And nurses felt they couldn't give the care that they'd been educated to give and wanted to give. Moral distress became high. So I think we've learned a lot about, again, the importance of the practice environment and how you organize nurses in the supports you give them. And it's all evidence based. It's all in the research literature.

Paul Anderson: Thinking about your role specifically as a nurse education program so distinct now from a provider organization. What are some of the particular challenges that you see that you're going to be facing going forward? I'll say, especially in the next couple years, again, as the sort of COVID starts to recede, we hope, and we start to try to fill this workforce. What are some of the particular challenges you're going to be charging into?

Heather Brom: Thinking about kind of the challenges moving forward, and I would say kind of experiencing in the classroom now is students are kind of having to come back together and be in person and kind of transitioning back from that remote learning environment to the in person venue. And I think it's thinking about like, is this the way that it works for all for it to be delivered? So kind of one is that modality. And second again, is really trying to find those clinical rotations and those sites where students can really have immersive experiences. And again, how do we kind of incentivize getting more of those to be able to increase our capacity to enroll students?

Donna Havens: I think something that happened at schools across the nation and maybe across the world is because those clinical sites were not readily available because they didn't have enough nurses to be able to help educate student nurses, their clinical experience to some degree might have been shortened or lessened. And so schools across our nation resorted to simulation labs. We have an excellent SIM lab. Most schools do. And we had only been using it for 10% of their education, but we upped it a little bit. Now I have to say, we're hearing from employers that they came out with noticeably different skills, especially in terms of a higher level of critical thinking they told us last year's graduates. And I believe it's because of the simulation experience, the debriefing, the repeating it, the group learning, but they may not be quite as skilled with some of the hands on things that they would have gotten in the actual clinical settings. But that can be taken care of in the clinical settings, through residencies and internships and expanded orientation. So that's going to be different going forward.

Paul Anderson: So Heather, we've been talking a lot about the role of nurses and the current nursing workforce shortage and so on, but obviously there are lots of other kind of providers right in a provider organization. And so what do we know about the role of, let's say, advanced practice nurses in this puzzle of trying to make sure that we're taking care of patients?

Heather Brom: Yeah, thanks Paul. So nurse practitioners have been specifically kind of one of our advanced practice nurse subtypes have been a really growing profession and gaining more attention, especially in primary care settings. And this has kind of been coupled with a decrease in physicians going to primary care, our kind of aging population, access and expansion with healthcare insurance as well. And we have lots of research really looking at the outcomes of care of nurse practitioners and the quality and finding we provide very high quality care. But one of the kind of constrictions really that has been going on the last two decades are the scope of practice laws for nurse practitioners. So nurse practitioners are certified nationally, that they take their exam after their education, but then how they're able to practice is then implemented at the state level, and then even within some practices can restrict it further. And we found with these places that have, or states with more restrictive scopes of practice, access to care is less for patients. And so kind of one way that we've been working on that is to be able to expand scope of practice, to encourage more states to allow nurse practitioners to practice to their top of their license and be able to provide more care services. And so what was sort of interesting. So with the Affordable Care Act passage in 2010, we saw kind of this burst of states be able to kind of take that policy window of opportunity to further advance legislation around scope of practice. And then with COVID in 2020, there were several states with kind of emergency orders to either suspend or waive these collaborative practice agreements which were required between NPS and physicians, and also bolster their ability to provide telehealth. So we were able to kind of in a short period of time kind of pivot and allow better access for patients to get care from nurse practitioners. So it'll be kind of interesting to follow kind of how can we keep that momentum going with it? You can also think about the scope of practice of our nurses as well. And kind of how has that been constrained during COVID with staffing shortages or not having the right resources or enough support on your care team to be able to really practice at your top of license too.

Paul Anderson: We talked about a lot of the challenges and barriers that we see facing nurse education and the workforce and staffing, and so on, going forward, but are there opportunities that come out of this situation where we can look forward and say, ah, may maybe now we have a chance to do things differently than we had in the past?

Heather Brom: Yeah. I think, it's a issue, a point I brought up earlier, but really thinking about how do we kind of reconfigure how nurses are working, or how do we really bring the idea of kind of work life balance, which I think is becoming more and more valued across professions to work where we're used to sort of this eight hour shift or this 12 hour shift where your time is just kind of devoted right there at the bedside. What ways can we encourage breaks or support breaks or time away, other ways that we can promote nurses to be at the bedside, but to either advance through clinical opportunities or other educational opportunities as well.

Donna Havens: I think we can encourage more people to enter the nursing field as we've seen happening with the second degree programs. I mean, we have artists and attorneys and musicians becoming nurses, and we're seeing far more men entering those second degree programs also, which we truly need in nursing. But in terms of what a graduate comes out of a nursing program prepared to do, I think they're going to be much more aligned with remote health monitoring, digital health, all kinds of things that we're having to rely on now. And these new graduates are going to be really good in that area so we're trying very hard here to give them those experiences.

Paul Anderson: I always like to wrap up these recordings by asking for sort of a first step. What's something that an organization, and I'll say maybe you could think about whether it's from the perspective of again, an education program or whether it's a provider organization that you're feeding nurses into, they're not going to solve all this today, but they can start today. And so if I'm an organization, what is that sort of critical first step that they have to take that sets the scene for everything else that they need to do going forward?

Donna Havens: I think create an evidence based nursing practice environment. Many had done it in the past. They lost it during COVID, but they know what to do. And they can do that relatively easily. It's going to take time, and it's going to take money actually, but they can regain that excellence in practice through that.

Heather Brom: I think kind of piggying back off of that, it's really inviting nurses at the table where you're making decisions to not only hear their voices, but take steps to enact changes. So whether it's something small leading up to something larger, but again, showing them that kind of that buy- in is there, that you want to retain this nursing workforce in your organization.

Paul Anderson: So Dr. Brom, Dr. Havens, thank you both so much for joining us today. You can learn more about ECRI and the ISMP PSO from the ECRI website at www. ecri. org, where you'll find our 2022 top 10 patient safety concerns report which includes staffing shortages as the number one item in the list. You can reach our guests at donna. havens @ villanova. edu and heather. brown @ villanova. edu. Be sure to subscribe to Smart Healthcare Safety on Spotify, iTunes, Google play, or wherever you get your podcasts to get our latest episodes. We welcome your feedback. Please visit us at ecri.org or email us at ecri- podcasts @ ecri. org.