By Randena Hulstrand, Vizient
While it's not surprising that the nursing workforce continues to face uphill challenges post COVID-19 — as evidenced by the total supply of RNs decreasing by more than 100,000 in 2021, a far greater drop than ever observed over the past four decades — it may leave some wondering how healthcare systems will regain their footing. According to a January 2022 survey conducted by the American Nurses Foundation, 12,694 nurses indicated that very few of their organizations had taken steps to address staffing shortages outside of bringing in travel nurses and increasing wages.
These shortages have created growing obstacles in balancing healthcare delivery and workforce requirements, along with much discussion on how to address. Eric Burch, executive principal, who leads operations and workforce at Vizient, describes the crisis as a resource and demand mismatch.
"From an organizational capacity standpoint, having beds is one thing. But having beds with the appropriate staffing is another — and there are no two ways about it, they must match," he said. "We have to look across the system of care and understand how care is currently being delivered and embrace fresh, innovative ideas."
To tackle these issues and foster discussion, Vaya Workforce, which helps Vizient members with temporary and permanent staffing needs, brought together a group of leaders from health systems across the country in November 2022 to trade stories about these challenges in a collective "Think Tank" — and to share some of these promising innovations.
One of the facilitators, Melanie Bell, senior vice president of fulfillment and strategy at Vaya Workforce, said, "Utilizing the findings of the multi-organization collaborative Nurse Staffing Task Force as a foundation, we had industry experts drive discussions on three main topics that were identified as core to solving the nursing challenges that healthcare organizations are facing today — healthy work environment, employment flexibility and innovative care delivery models."
Facilitator Jennifer O'Connor, principal, who leads workforce research for Sg2, a Vizient company, offered perspectives from her experience working on strategy with organizations across the country. She emphasizes that the smallest steps that a healthcare system can make toward improving their workforce can be the start of significant incremental change, but there is more to do.
"As we've watched healthcare issues unfold over the last 18 months, almost all organizations started with small steps such as looking at competitive hourly wages," she said. "But those who we've seen really come through with momentum and a sense of, ‘We will get through this,' have been willing to embrace thinking differently, doing things that are a little bigger such as creating varying length shifts, utilizing job sharing opportunities or offering free tuition for nursing students to get them into the pipeline faster."
Read the following Q&A discussion with Burch, Bell and O'Connor about specific "bigger step" innovative solutions that were illuminated in the Think Tank and why healthcare systems must actively change how they've traditionally approached managing their workforce — sooner than later.
Q: When it comes to innovative care delivery models, how can the use of technology be game changing?
Burch: In thinking about innovative technology, there's virtual and digital capabilities and then there's the opportunities that artificial intelligence can provide. Leveraging clinicians to do part of the care delivery through a system where they can monitor, assess and be part of the care team remotely is exponentially beneficial. This will allow organizations to expand capabilities and provide patients with expertise that may not be available otherwise.
For AI technology, it's taking all the data and information that we collect to create better workstreams that may lead to a quicker diagnosis, such as the ability to look at records and interpret medical or diagnostic outcomes and findings in a way that leads to faster decision making and aligning treatment plans. This technology will lead to better productivity and improve efficiencies.
Bell: The industry anticipated many years ago the emergence of electronic health records was going to create efficiencies for nurses, but that was not the case. They create amazing data, but they also create a lot of administrative burden for our frontline clinicians. Some studies show that as much as 40% of nurses' time is being spent documenting instead of providing care, and that's valuable time that these highly skilled professionals are spending on tasks that have simple technology solutions. For example, if doctors can dictate their patient care and surgical notes, why hasn't healthcare moved to a point where nurses also can? Being able to dictate an assessment at bedside is not only time saving, but it opens opportunities for nurses to focus more of their time on conversation and patient-centered care.
Q: What are the biggest obstacles to the virtual workforce model?
Bell: The industry is going to have a gap of as many as 450,000 nurses by 2025. There is not time to bridge that gap in the timeframe it will take to develop them. Because of this shortage, a virtual model will be imperative. The hardest part about embracing a virtual model is getting people to fundamentally change their work, how they do it, when they do it and who they do it with. Even when looking at clinical practice, the gap can be 15 to 20 years from new evidence to implementing that practice. Healthcare can't afford to move that slowly.
O'Connor: There are obstacles, but I think some are false. Some leaders assume that patients won't want an eye/voice from the ceiling watching over them because it's intrusive, and that they don't want to interact with technology that way. But in looking at recent consumer surveys, patient populations are getting very comfortable with technology in all settings if it has a purpose. If they can get more attention as a patient or be discharged quicker, they are for it.
Q: How can different support services alleviate the burden on over-taxed nurses?
Bell: When you think about lift, transport, IV and phlebotomy teams — the ratio of unlicensed support personnel in comparison to RNs has gone back and forth over the years, and the latest trend has been to eliminate a lot of those support services. There are not enough RNs, and they are the ones absorbing all the extra work. There's been a huge push to get all RNs to be bachelor's degree prepared. But the level of scope that they can operate at is higher than what is often asked: At least 50% of the work doesn't require an RN licensure. Utilizing unlicensed assistive personnel who can help the patient to the bathroom, can get them water, go find an IV pole — tasks that don't require a registered nurse— can help nurses feel safe and avoid burnout.
Q: What innovative care delivery models from the Think Tank Report stand out to you as sustainable options for the future?
Bell: Virtual anything — nursing, physicians, specialists — that can be incorporated into a remote world in this new working environment is key to evolving and transforming the care delivery model. For example, a healthcare organization in the Southwest shared that their virtual wound care program resulted in 38% increase in number of patients seen with same number of staff in prevention rounds and one of their sites offering a virtual acute care and ICU surveillance program reported a decreased incidence of code blue by 70% and had saved 111 lives over a five-month period. Additionally, if nurses can live in an area where the cost of living is significantly lower than where they are providing their services, they're likely willing to work for less. When you have these opportunities to leverage technology, it is a benefit to the workforce and organization.
O'Connor: Also, this same organization surveyed their nursing staff and found overwhelming requests for job sharing flexibility to eliminate burnout and build new skills. For example, oncology nurses wanted to work two days a week in the more intense IP bone marrow transplant unit and three days a week in the outpatient infusion clinic. Others wanted to split time between a lower acuity med/surg unit and learn skills to enable part-time work in the ICU.
Another innovative approach: an academic health system in the Southeast modernized their float pool to increase shift fulfillment and worker engagement by adopting Shifts' cloud-based software with mobile app capabilities. One hundred percent of their float pool workers use the app on their phones to accept open shifts at 133 of their locations. They've seen success with this approach for just-in-time RN, CNA, LPN and admin staffing, and are expanding it to other roles as well.
Q: Why is it important to tie investments in a healthy work environment to increasing revenues and/or decreasing costs?
O'Connor: Workforce is typically 60% to 70% of the expense base for any hospital. So, if organizations are going to do something different, it's typically an added expense. In 2022, healthcare systems wrapped a year of negative margins. Any investment requires an extensive justification, even when it's the right thing to do. So how do systems recoup this investment? Averting turnover in the workforce yields immediate and obvious cost savings — reduced recruiting and onboarding costs as well as decreased contract labor expenses. Hospital executives should also keep in mind that studies routinely link nurse satisfaction and turnover to clinical outcomes and patient experience, which has financial implications in today's value-based payment schemas.
Bell: Healthcare is a human-element industry, requiring hands at bedside to deliver care. 4% of 25- to 35-year-old nurses left the industry in 2021. It's not that they moved, went from inpatient to outpatient, inpatient to corporate or retired. They gave their registered nurse licensure up during the year. Let's take a hard look at how to utilize them appropriately, not creating more work for them, but allowing them to work at the top of their scope.
Q: Despite the current challenges of the nursing workforce, what affirms your hope that this industry will thrive?
Burch: Nursing has a real tenacity to adapt. I see a lot of passion within the profession that will translate into newer and innovative models to better approach team care. Allowing nurses to work more at the top of their license and really embrace technology is an opportunity to expand the way care is delivered.
Bell: As a society, we expect that we're going to get great healthcare. I am cautiously optimistic that as an industry we are working to meet those expectations by accelerating workforce innovation and transformation. Recognizing the need for change and providing the resources to accelerate that change will help us navigate our way through this.
O'Connor: There's much being written about workforce. As a former student from the University of Illinois, I recently read in my alumni magazine about a university partnership with Carle Foundation Hospital that created a new medical school that is anchored in engineering principles — with the idea of combining medicine and engineering to innovate healthcare. The first graduating class this year is creating new tools, devices and apps to address better care and many have workforce implications including a smartphone app to bridge non-English speaking patients and their medical staff. This is a great example of empowering our healthcare innovators of tomorrow in new and different forums. The future is promising.