Staff Shortages and Health Care Reform
A story on the front page of The Jackson Sun, 21 September 2021, reports the National Guard has deployed some 400 troops, 30% clinical, to 31 hospitals across Tennessee to help deal with staffing shortages. As the article notes, though, many of the medical personnel are already working full-time in shortage areas. Other news stories have reported on continuing staff shortages, particularly nurses, across the country. While payment reform has not yet produced a reorganization of health care delivery, chronic shortages of nursing staff will.
In all fairness, nursing staff shortages has been a cyclical theme during my career. When economic times are tough, the appeal of nursing tends to go up and vice-versa. So, an obvious question is whether this time is different? I suspect it may be, because this time the mortality risk of nursing is evident to all. Furthermore, in times past, many young women with nursing licenses would periodically drop out to start families or care for their children, but would keep their license active, so they were available to re-enter the workforce if the pay and working conditions were enticing. However, availability was, and is, contingent on reliable daycare. If a relative was not available, this meant using commercial options, but, as is readily apparent, the daycare business has experienced even more staff disruption than health care. Getting this reserve workforce back, then, likely means offering reliable, work-based daycare. Of course, this is another unfunded expense for hospitals at a time when resources are already stretched.
The nurse shortage is not unique to the United States. As Cattron and Iro note:
“The effectiveness of healthcare is inextricably linked to the state of the nursing profession…Frailties in healthcare systems, exposed by the COVID-19 pandemic, reinforce the urgent need for all governments to invest heavily in nursing to bring such fundamental change.”
They cite a 2020 report on the world-side state of nursing. “Nine out of 10 nurses globally are female, and one in six countries have fewer young nurses than nurses expected to retire in the next 10 years.” The report estimates a global shortage of 6 million people, plus another 4.7 million needed to replace those expected to retire in the next decade.
They had several recommendations, but the issue that resonated the most with me was “valuing nursing.”
“Nurses are valued for especially for “being there” for their patients and their loved ones during life’s most challenging moments. This has continued throughout the pandemic, with nurses often standing in for loved ones while patients died, providing comfort and compassion in their last moments.
Traditionally, this kind of care and compassion is associated with love, an aspect of nursing that is important to people, particularly when they are struggling to deal with complex, long-term, and terminal illnesses. Compassion is a key aspect of healing and can affect the delivery of quality health outcomes. Nursing with compassion places people at the center of care, but nursing is much more than this: it is both an art and a science, requiring intelligence, skill knowledge, and most importantly, high quality education.”
You may disagree with this description of nursing, but I think it is fitting. But note, of the key virtues cited, love, compassion, and “being there,” only the last one is easy to measure. In the numbers-driven management systems imported from other industries, with its emphasis on efficiency and “lean” management, love and compassion are not measured, or may be unmeasurable, and so are often simply ignored or only given lip-service.
There are two other challenges, also difficult to measure, that need to be addressed. The first is getting physicians to stop undervaluing nursing input. There may be many historical reasons for this, but the primary one is a sort of “Lone Ranger” spirit common among physicians. It has been my anecdotal observation that, as the number of women physicians increases, some of this goes away. But I have also seen instances where nurses disrespect women physicians in ways they would not to a male physician. Clearly, there is room for improvement on both sides. But making improvement is going to require a deliberate program. One of the best ideas I ever heard was when a hospital created a new ward staffed with their best and brightest nurses, but allowed only select physicians to admit to it. A condition of continued admitting privileges was on treating the nurses as partners in patient care, not staff.
The other challenge is getting rid of horizontal violence within the nursing ranks. I have discussed this issue at length in other articles. I have seen no documentation, but would not be surprised if the psychic stresses of dealing with the pandemic has sapped the emotional reserves necessary to keep that from happening. Again, a thoughtful, directed program to address the issue will be necessary.
The last challenge is to recognize delivering care “the way we always have” cannot be done for the same or increasing numbers of patients given persistent staff shortages. While some aspects of care, like ICU care, likely require high staffing levels, experience during the pandemic has shown that use of other trained staff, like respiratory therapists, can stretch limited resources safely and effectively. On the other hand, the shortage of staff is likely to make the value of outpatient care, where less staff are needed per patient, even more obvious. Institutions that have prioritized in-patient care having been trying to pivot to out-patient care for financial reasons. Now they may have to accelerate the trend to alleviate staffing problems.
While all these are challenges, this may also be an opportunity to re-think what is essential to care. A lot of what clinicians at all levels do is really “busy work.” What if we got rid of the non-essential elements? Defining “essential” is difficult, but consider how much time is spent entering data into a computer that no one ever looks at? While computers and charts aren’t going away, maybe now is the time to restructure notes using a “Wiki” format, for instance, as discussed in other articles. There are many others, some of which may be specific for a given organization. While it is difficult to think past the crisis of staff shortages, too many patients, and too little money, those who can be bold may be in the best position to thrive once demand induced by the pandemic abates.
21 September 2021.
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Wouldn't it be wonderful if we got rid of stupid stuff?