Staffing shortages in hospitals have been a concern for some time, owing to the country’s aging population—but COVID-19 has only worsened the situation. In reaction to the pandemic, many of these institutions spent months stockpiling medical equipment and protective clothing, but the supplies are useless without staff. So, how do we handle the hospital staffing crisis?
Despite recent decreases in coronavirus infections across the country, many hospitals are still facing staffing shortages, and may continue to do so in the coming months. Healthcare workers are still under a lot of pressure, experiencing deplorable working conditions. Many of them are unable to take much-needed breaks due to severe personnel shortages, and suffer burnout as a result. The stress levels are so high that some are even considering leaving their professions entirely.
Adequate staffing levels in healthcare institutions ensure a safe work environment for healthcare workers and quality care for patients. Hospitals must be ready for potential personnel deficits and must have contingency plans and workforce management tools in place to deal with them.
COVID-19’s Impact on Healthcare Staffing
In 1999, the state of California enacted and implemented the first and only comprehensive U.S. legislation limiting the number of patients that nurses may care for at a time. Although several studies show how better staffing leads to improved patient outcomes, no other states have adopted this type of legislation.
There are many reasons why efforts to pass legislation governing hospital nurse staffing fail to get universal support from influential groups. The first impediment is a lack of local and timely evidence to support such laws. Another is the misconception that the country lacks nurses. Meanwhile, registered nurse graduations have more than doubled in the last 15 years.
The COVID-19 pandemic served as a stark reminder of the significance of adequately staffed health systems in delivering high-quality patient care, as well as the toll that under-resourced facilities have on workers’ well-being. The rising patient demand and diseases among healthcare professionals, particularly those of ethnic minorities, significantly impacted staffing in healthcare, worsening the staffing crisis even further.
Many hospitals responded to the surge in patient demand by canceling elective treatments and shutting down non-essential outpatient clinics, but dealing with the shortage of personnel was more difficult. Healthcare workers were repurposed, and students were onboarded at the worst-affected hospitals. Some states provided temporary allowances that permitted nurses licensed in one jurisdiction to practice in another during the heat of the crisis. Nurses were allowed to work across state borders and in areas with severe shortages.
What Can be Done About the Recent Healthcare Staffing Crisis?
While no one has the one-size-fits-all solution to staffing shortages, it’s fair to presume that healthcare providers would benefit from being more proactive than reactive in their staffing strategies.
The absence of flexible workforce management is now the most common cause for nurses leaving their first year of employment. Clinicians must sign up for shifts eight weeks in advance, and there is little leeway to readjust the schedule once it has been completed. Shift allocation is inefficient and largely reliant on manual systems, which undoubtedly isn’t suited to any last-minute changes.
Nurses and other clinicians prefer to specialize, but with further training and development, nurses may cover shifts in various departments and situations. While tenure in a department is frequently used to determine a schedule, this strategy results in nurses concentrating in one specialty and limits multidisciplinary training. It’s possible that tenure isn’t an excellent criterion for scheduling.
Pipelines for candidates
Though the number of registered nurses graduating yearly is at an all-time high, there is room for more. Other healthcare fields are still producing fewer professionals than there are jobs available. To recruit future healthcare workers, healthcare companies must be future-focused in their workforce planning, building stronger relationships with high schools, colleges, and training centers.
One of the most effective methods to guarantee that patients receive the treatment they require is to lower the likelihood of healthcare workers being sick. Infection prevention teams must make a concerted effort to offer timely and complete information to employees so that they can protect themselves.
Hospital executives must also change their workplace culture by encouraging employees and managers to speak out when they observe colleagues missing a chance to improve safety. It’s critical to reinforce the idea that everyone has the right to contribute to a workplace that is safer for other employees and patients.
Employing Digital Tools
One of the numerous advantages of telehealth adoption is that nurses, doctors, and other hospital personnel may care for patients online, while quarantined or recuperating from sickness. Furthermore, hospitals may centrally control all elements of their treatment operations thanks to digital health care delivery.
Staff can also use digital technologies to communicate between hospitals, e.g. during surges, to lend support at all levels. Critical care teams, in particular, can cross-cover patient spikes.
The staffing crisis in healthcare may continue for some time due to the ongoing COVID-19 pandemic, poor workforce management, and low adoption of digital transformation in the sector. The government also has a role to play in enacting legislation that regulates patient-to-health worker ratios. With adequate adjustments, the deficits can be filled and care delivery optimized.
The recent news of elite Olympic athletes prioritizing their mental health and their own physical wellness over their sport has focused a national spotlight on the complexities and the prevalence of mental health struggles. And while seeing people who are suffering from mental health issues is difficult, the athletes’ public struggles have opened a door that allows healthcare providers to raise the issue with patients and loved ones.
In some minority communities, mental health struggles remain taboo to discuss openly. People who are experiencing symptoms of illness such as depression, anxiety, or obsessive-compulsive disorder, or even life-threatening suicidal thoughts face a stigma that prevents them from even seeking care. When the issues are discussed, access to affordable and high-quality mental health providers can be a barrier to getting help, as can lack of insurance and any language barriers.
According to the OMH, mental health is a serious and common health issue with approximately 18 percent of the entire U.S. population having a diagnosable mental illness within any given year. Of that percentage, only 43 percent of people who need mental health care receive treatment or counseling. For minority mental health needs, the numbers are even more concerning. While 48 percent of whites receive care, only 31 percent of Blacks and Hispanics do. And statistics for Asians were even lower at just 22 percent receiving needed mental health services. Disparities in mental health care can lead to lack of treatment or ineffective treatment.
For most people, mental health treatment is effective and improves their quality of life. Whether people choose medication (psychiatric nurse practitioners are especially), talk therapy, or a combination of both, getting help can make symptoms abate significantly. In more transient cases of mental illness, for example depressive symptoms caused by a major life change, treatment can get someone back to feeling like their old selves and can improve their resiliency moving forward.
These care disparities have lasting impact. According to the American Psychiatric Association minority and white populations have similar rates of mental illness, with white populations being slightly higher in some instances. But when Black and Hispanic people have depression, for example, the effects are more persistent. And systemic racism plays a role in proper care. The report states that “Racial/ethnic minority youth with behavioral health issues are more readily referred to the juvenile justice system than to specialty primary care, compared with white youth.” If mental health needs aren’t addressed and youth don’t receive proper care, that can lead to a disciplinary cycle that impedes educational and employment opportunities.
As a healthcare provider, keeping conversations about minority mental health open and ongoing with patients and having easily accessible resources available can make all the difference to helping patients get the care they need. From understanding the different types of mental health professionals and what they do to addressing medications or alternative therapies in a comprehensive treatment approach can help patients understand the range of help available. And with a recent uptick in the availability and acceptance of virtual therapy appointments, accessing care is somewhat easier for people.
Raising awareness and broaching the topic about minority mental health is important to removing the stigma and helping people move toward care that works for them.
While the worst of the COVID-19 pandemic seems to be behind us, the spread of the Delta variant indicates that it’s not completely over yet. During the height of the pandemic, nurses worked on the frontlines all over the country, and some are just now sharing their experiences working in the ER during the height of COVID-19.
Rastisha Smikle, RN, works in an ER at a hospital in central Florida. Having worked as a nurse for more than 10 years, she answered our questions about what it was like in the ER during COVID-19.
As a nurse in the ER in Florida, what has it been like working there during COVID-19? How has it changed over the last year or so?
It was very challenging to work during the pandemic. In the ER, we are a patient’s first point of contact, and because of that, our staff is considered at a higher risk of being exposed to the virus. Although safety and infection control elements have always taken priority in our roles, the unknown factors of the virus’ transmission, ever-changing symptomatology, and treatment contributed to our challenges because of all the unknowns.
Patients were more fearful than ever; they often came in anxiety-ridden wanting testing because of recent exposures, which added additional challenges because the critical emergencies also relied on our care.
In some ways, things have gotten better. As we have learned more about the virus and therapeutic treatments, patients are being cared for more efficiently so that they can recover at home. Unfortunately, hospitals nationwide are busier than ever right now. The volume that we are seeing is higher now than we saw during the pandemic. It’s tough to say what that is.
Did your duties change during COVID-19?
My duties didn’t change per se, but the way we cared for patients did.
Before the pandemic, PPE like N-95 masks were not permanently a part of my uniform. Now, I wear an N-95 and face shield with every patient encounter. Because of the wide range of symptoms, we have to be extra diligent in caring for patients just in case they have the virus and aren’t aware of it yet. In addition, minimizing my exposure time with known Covid-19 patients is also an element that I have had to implement in my care. For the safety of myself and the other patients, swift patient care must be implemented with these patients when appropriate.
Employing the use of hospital phones has been a way that I try to fill in the gap. Throughout this time, I have learned how fearful patients are after they get the diagnosis. With these talks, I can extend some reassurance, listen to their concerns, and figure out thoughtful and effective ways to help them with the emotional challenges that often accompany the diagnosis and isolation.
Was it scary to work there in the beginning of the pandemic? Why?
There was a level of fear when it came to the unknowns. I had worries about getting the virus. But primarily because of my level of exposure in the ER, I was mainly concerned about others being around me. I isolated myself from family and friends, and my life was work and home.
There were times when we would care for patients with no known symptoms and later, we’d find out that they were positive for Covid-19. I would have mounting thoughts of whether I wore the correct PPE or if I was exposed in those moments.
We also had staff members contract the virus, which was scary. Thankfully, most of them recovered well, but seeing how careful other staff members were and finding out that they still contracted the virus was nerve-wracking. Every minor allergy symptom or cough would cause concern and anxiety about whether I was next. To combat those fears, I had to reshape my focus. Instead of being hyper-focused on getting sick, I began to fix my focus on doing my job well and providing the optimal patient care that I was used to. With this newfound focus, my anxieties slowly began to dissipate.
How do you keep yourself from bringing the stress of the job home? What do you do to relieve your stress?
Sometimes it can be challenging, especially after losing a patient. My go-to stress reliever is prayer. I have a solid spiritual foundation, and thankfully the organization I work for also provides spiritual support, if needed. As nurses, we are fortunate enough to work three shifts per week. I try not to take my days off for granted; I use that time to refuel. Therapy, exercise, and self-care activities have been essential to my mental well-being.
What are the biggest challenges of your job—especially during COVID-19?
One of the biggest challenges of my job is knowing that I have to be on my A-game at all times because the safety of myself and others depends on it. The unknowns that came along with COVID-19 made it challenging to do and be our best. For example, we didn’t always know the best course of action when treating some patients because everyone would respond so differently, which posed one of the biggest challenges. Thankfully, as time went on, we learned more about the virus, the treatment options that worked for others, and we eventually adapted very well.
What have been your greatest rewards during this time?
My greatest rewards have been seeing how the nursing and healthcare community banded together during the most challenging times. The support from our community members was also very inspiring. We often came into work with goodies from companies that wanted to encourage and thank us for our continued work.
Throughout my tenure for nearly 20 years as a nurse, nursing professor, and leader in higher education, I have learned a lot about the art of successful coaching. In both traditional, and non-traditional academic environments, no matter whether you connect physically in-person or virtually via video-conferencing, effective coaching can not only transform a nurse or student, but everyone they come in contact with, and ultimately an entire organization.
My proudest moments in leadership have been when I have helped my faculty have “light-bulb moments,” and deep moments of personal discovery. Discovering perceived versus actual obstacles in their teaching methodologies, and personal lives triggered powerful breakthroughs that left them forever changed. In a recent experience, it warmed my heart to have a team of faculty so passionate about student success and improved student outcomes, that they were willing to take a deep look at themselves and change anything that would hinder them from being the best professor that they could be. These faculty believed that transformed students started with transformed faculty. One particular cohort of nursing leaders I had the distinct pleasure of coaching were all geographically dispersed so we used a videoconferencing platform to meet as a group bi-weekly for 45-minutes, and one-on-one for 30 minutes for eight months.
During our meetings, I used evocative questioning and active listening to lead them on an individualized journey of discovery in personal and professional areas. The steps of the nursing process provided structure for our interactions. We started with the following:
Assessment: Defining where they are in their personal and professional lives, from a holistic perspective
Diagnosis: Identified area of opportunity for growth
Plan: Intentional action steps to achieve the goals
Implementation: Executing the plan
Evaluation: Reflecting on the journey, including personal and student outcomes
There were many lessons learned from this experience, but the greatest takeaway was that each faculty member personally experienced a fundamental internal shift and a personal transformation in their mindset and skillset and felt empowered to apply the lessons of their personal growth to student interactions and teaching methods. The application of the lessons they learned through my transformational coaching program not only enhanced their confidence in teaching, but also improved their coaching skills, student support, and student outcomes.
As an emerging nurse leader, I remember my mentor telling me that as I continued to teach nursing that my students would teach me more than I ever taught them. This was very true. The inspirational and empowering professional I desired to be for my students became an ever-evolving journey of self-discovery and becoming. I have been able to achieve extraordinary things throughout my nursing career because of mentors who allowed me to “borrow their belief” in me. Having someone to help you “unpack” personal and professional challenges, and change your perspective about adversity and obstacles has been priceless, totally life-changing, and essential for my growth. If nurse leaders seek to build more nurse leaders, mastering the art of effective coaching is critical.
The Future of Nursing 2020–2030 Charting a Path to Achieve Health Equity report, issued by the National Academy of Medicine Committee on the Future of Nursing 2020-2030, is addressing topics that will impact the nursing industry in the coming years. Sponsored by the Robert Wood Johnson Foundation, the report examined issues and topics foremost on the minds of those in the industry and brought forward recommendations to help guide important changes including scope of practice regulations, health and well-being of nurses, and better payment models.
Currently, 27 states restrict the autonomous practice of nurse practitioners, despite the nurses having the education and training to practice in such a manner. With advocates working to remove these remaining restrictions, Cunningham says the progress is happening, but slow. “Each state has regulations that govern advanced practice registered nurse scope of practice,” she says. “When we say APRN, there are really four groups of nurses we are talking about. Most commonly it is nurse practitioners, but also includes certified nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists.” The report also looks at the institutional barriers for other nurses, including registered nurses (RNs) and licensed practical nurses (LPNs), to allow them to practice to the top of their education and training.
The restrictions have been loosening ever so slowly. “There has been considerable progress in this area, I will says that,” says Cunningham, “but it has taken a couple of decades. There are 27 states that don’t allow APRNs in those states to do things they are educationally prepared to do. Examples include prescribing medicine, diagnosing a patient, and providing treatment independent of a physician. Even when it is allowed, there are administrative burdens. It’s not a very nimble system.”
Increasing Access to High-quality Care
The Future of Nursing report did a lot of research on the elements and regulations that limit access to care in general and to the high-quality care offered by APRNs, says Cunningham. And while opponents say that non-physician providers are less likely to provide high-quality care because they don’t have the same training or clinical experience, Cunningham disagrees saying the data doesn’t show that quality of patient care is reduced. “Arguments are made against scope of practice being relaxed really are not keeping the patient at the center of the discussion and it should be at the center of the discussion,” she says. “APRNs bring specific skills and knowledge. In states with restrictions, patients have less access to primary care.”
What autonomous practice does, she says, is significantly increase access to care, especially in rural and underserved communities where physician care may be scarce or difficult to access. APRNs aren’t looking to practice brain surgery, says Cunningham. What they will do, and are trained to do, is provide high-quality primary care services.
At various times, changes to these rules have proven to be especially effective. Interestingly, Cunningham says the COVID-19 pandemic inspired eight states to suspend scope of practice restrictions as a key strategy to manage the pandemic care in the interests of the public and when the health of the nation was at risk. The strategy worked so well, some of those states have moved to make those changes permanent, she says. In 2016 APRNs also saw expanded practice regulations when the Comprehensive Addiction and Recovery Act allowed nurse practitioners to prescribe buprenorphine, a drug used to manage addiction, says Cunningham. The bill increased access to care in rural areas and helped keep patients with substance use disorder safe. When federal authority supersedes state regulations (such as this instance), says Cunningham, that should be looked at more closely as it gives evidence of how loosening regulations can protect public health.
Reducing Administrative Burden
Granting nurses autonomy also helps organizations stay nimble, says Cunningham. It allows them to move nurses where they are needed during times of crisis like COVID, without the extensive forms and processes typically required. COVID, says Cunningham, showed how being able to move nurses to different areas to treat patients or to cover for nurses who were called to a different area, was essential to patient health.
And while the immediate outcomes look positive, Cunningham says the data that emerges from the pandemic will tell a more complete story. “Reductions in mortality especially will be the kind of outcomes data that will be compelling to make this permanent,” she says. “The current recommendation is that all changes that were adopted in response to COVID should be made permanent by 2022. That’s a strong recommendation coming out of the report, but there’s good data to show this is a strong direction.”
Improving Care Access Through the Workforce
And the sheer number of working APRNs would offer a significant boost to primary care efforts where they are especially needed such as in rural or low-income areas. “For counties that are deficient in the number of primary care providers, meeting the needs of the population is important,” says Cunningham. “It creates more equitable communities.”
To remain focused on the patient, the report’s findings show many ways APRNs are trained and educated to improve patient outcomes. “We should be focused on the health of the nation,” says Cunningham. “The current situation is antiquated given the health concerns of the nation. It is not focused on the patient. We need to ask, ‘How do we improve the health of the nation?'”
The report finds removing restrictions also has other benefits. “The clinical piece of this,” says Cunningham, “is that it would be extremely empowering for nurses to do all the things they are prepared to do.”
Although Henderson says community health is covered in nursing education, the standards in place don’t reveal how often or how well community health and public health nursing competencies are covered in individual programs. Sometimes it’s just as one course or an elective course.
“We argue in the report that these areas of community health, public health, social determinants, and population health need to be comprehensively threaded throughout the curriculum,” Henderson says, “so it’s not an add-on. It’s baked in fundamentally into everything we do in our nursing practice.” As nursing education changes, schools and students will begin to collaborate more across disciplines.
Changing how nursing is taught and how students gain experience means more nursing students need to spend time working in various community settings. Nurses learn best through experiential learning, says Henderson, especially with community-based social issues. “Put students in the community and put students in settings where they are finding experts,” he says. And when students find the specialty that appeals to them, letting nurses deviate from the typical path will get them started quickly. “Telling nurses they need one to two years of med-surge under their belts is unnecessary,” says Henderson, “and we have to stop perpetuating that.”
Experience in the Right Settings
For nurses who know they aren’t interested in a med-surge path, those two years could be better spent gaining targeted skills. Immersing themselves with on-site community health work strengthens their commitment to the role.
“Without that kind of immersion, you are reinforcing stereotypes because what you read is not contextualized by what happens,” says Henderson. For instance, he says, nurses may read that “because you’re African American, you’re more at risk for ‘A'” or “because you live in this community, you’re more at risk for ‘Y.'” It’s not contextualized as to why any health impacts are happening, he says.
Nursing education depends on nurses understanding the socioeconomic influences of disease. Henderson says nurses who are immersed in a community may see that patients lack access to green spaces to exercise or may not feel safe in their neighborhood. They may see patients don’t have easy and affordable access to healthy foods.
“The context is the patients don’t live in a community that sets them up to eat healthy, exercise, and take care of themselves to reduce the risk for something like diabetes,” he says. “It has nothing to do with them being African American and has to do more with community conditions. You have to see that and experience it.” Henderson, whose own career was deeply influenced by his early work in community health, says nurses can’t address the health needs in a community without addressing the social needs. “The community is the teacher,” he says. “We go into a community with preconceived notions. But patient-centered care is community-centered care.”
Reading something in a book gives nursing students a theoretical background, but going out into the community, often sparks a passion about uncovering a solution to the root causes of some of the issues patients are facing. “There are downstream effects of that,” says Henderson.
Shift in Nursing Education
As nursing education changes to a community focus, nursing students will need faculty leaders who can talk to them about how to change approaches to tasks like screenings.
“One of the biggest hurdles is getting students out of the mindset of I have to get out to do a specific task,” he says. “It’s about what kinds of conversations are you having during the screening when you’re checking someone’s eyes. Are you learning about their home life? In community public health, you’re exploring the issues that are surrounding their lives and the issues that impact their wellness so you can focus on intervention and prevention.” Nursing students have to be taught about it in their classroom work so they can merge their knowledge and hands-on experience to examine the root causes of illness differently.
Workforce Preparation and Qualification
People want to work in the settings they are exposed to, says Henderson, so nursing students should work in settings that let them see a nurse’s role in schools, correctional facilities, public libraries, preschools, community health centers, homeless shelters, and public housing, and learn from the experts who work in those settings.
Sometimes, says Henderson, the best professional to explain those topics are the ones on the front lines, like the social workers or school counselors who see people for issues that might not be related to an immediate health concern, but that most certainly impact health. With a chronic nursing faculty shortage, allowing educators who don’t have a nursing degree might help fill some gaps in staffing and course content, he says.
Henderson says the Future of Nursing Report calls for including curriculum topics around nursing policy, structural racism, and health equity to help nurses over their entire careers.
And, Henderson says, the report also advocates for nursing schools to address racism in society and within its own professional structures. “Nursing as a profession for a long time hasn’t addressed how racism has impacted our own profession,” says Henderson. “We say in this report we want to go out and do all this good and improve health equity, but we still have to clean our own house a little bit and examine how nurses of color are still discriminated against within our own schools and our own workplaces. And we talk about that in this report and that’s crucial.”
Higher education also must take a new look at its environment. “Schools of nursing need to acknowledge the impact of structural racism has within their own institution and how that disadvantages nursing students and faculty of color,” says Henderson. “That means critical examination of curriculum policy practices, curriculum strategies, and how they allocate resources. Who has the power and what do those dynamics look like?”
Diversity and Equity
A diverse, inclusive, and equitable nursing environment needs to be clearly defined. “Many people say diversity and think just by being diverse, we are equitable,” Henderson says. “But that’s not the case. You can be diverse but not equitable. You can have diverse people at the table, but it’s not equitable if they aren’t valued and their voices aren’t heard.” Lots of groups are recognizing that, says Henderson, but now they have to decide how to act on it and raise awareness about it.
Continually advocating for change in nursing and working to keep uncomfortable conversations ongoing and productive encompasses topics both new and historic, says Henderson, and is the focus of the next decades of nursing education. “It’s about who is having these conversations,” he says. “If we keep having the same people at the table, we won’t get far.”