I had a conversation with a friend this week where she expressed concerns about finding enough people to work in her health care organization, even though they were prepared to train them. She also was expecting increased losses from the vaccine mandate. I don’t have easy solutions to these questions, but they are not new. In fact, I remember similar conversations many times through the years. Nor are the problems unique to her organization—they are true in healthcare everywhere these days.
In November 2021 an interview of Charles D. Stokes about the nurse shortage was published. Mr. Stokes commented that when he took his first management job as assistant director of nursing in 1979, he spent much of his time recruiting nurses and nothing changed over the next 44 years. He went so far as to say he had never worked in an organization that had enough nurses. He reviewed the current state of affairs and noted he expects a major exodus of nurses once the crisis of the pandemic subsides and articulates many of the issues we have considered previously in discussion of turnover and team building.
“What nurses have always wanted is a voice in how the organization is run and how care is given. I always think about diversity as having a seat at the table, inclusion is having a voice in the organization, and belonging is having that voice heard. That’s what all caregivers want from their leadership.”
When asked about solutions over the short, intermediate, and long term, he observed that supply was chronically constrained.
“If there was some miraculous thing that happened, that even if we could train all the healthcare professionals we need for the future, the industry is not going to be able to afford them anyway.”
Based on this observation, he argues we are going to need care redesign, using trained technicians and others to “off-load” tasks, so everyone is working at “the top of their license.” Not only is this a financial imperative, it is also a way to make nursing more attractive to new people to enter the field.
Some potential solutions are managerial, such as changing work hours, job sharing, and even, as one large manufacturer in my area is doing, offering on-site child care. Some involve automation, an issue I have also pushed in the past, and is easier in some areas than others. But a challenge for most healthcare organizations is they have limited ability to increase revenue streams and the current inflation in the price of temporary help is causing financial pain which may not change as the pandemic ebbs.
In thinking about dialysis, the area where I have the most experience, I see real challenges to what passes for “standard of care.” Some years ago, one of my senior nurses did a time-motion study and determined an experienced staffer could initiate dialysis in 12 minutes. Taking the patient off also took about 12 minutes, but there was more variability due to bleeding from the access site. If the patient was not cooperative or not mobile, it took longer as well. It perhaps goes without saying less experience staff take longer. So, imagine a unit with two experienced nurses, one putting patients on and the other taking them off. They could get 16 patients on every four hours at best. This, of course, would not allow them to do anything else, including taking a break for themselves, and certainly would not allow for meeting the CMS documentation burden.
Realistically, we have operated for years on the notion the staff patient ratio needed to be no more than 1:4. If CMS documentation requirements were eased, perhaps 1:5 is possible, but likely not much more than that. If the staff person worked four 10 hour days in a week, then, they could staff care for no more than 20 patients, and realistically 16, (eight patients every 10 hour shift, but patients come 154 times/year on a thrice weekly schedule.) So, the staff shortages in dialysis means the time is rapidly approaching when the local dialysis clinic will have to say “no vacancy.”
So, what can be done? Perhaps the easiest answer is increased emphasis on home therapies, something that is a focus of both the government and the profession. But are we coming to a time when patients who can’t go home can’t be done? Some estimates show half the current dialysis population suffers from important cognitive impairment, making them harder to train and more likely to fail. Are patients who can’t go home going to continue to be accepted into in-center dialysis units?
The harder group is those patients who have co-morbidities that limit the likelihood of survival even with dialysis. Patients in nursing homes with local functional status, for instance, usually do not get a meaningful extension of life beyond the 90 days or so they would get from medical management. Are the days when all patients with kidney failure are offered dialysis coming to an end, not because of medical criteria, but because there is no place to go because there are no staff?
These are not just theoretical musings. One unit in our area has already closed due to staff shortages, and perhaps others are not far behind. Nearby units are struggling to accept these patients in transfer, as they were already short-staffed. Even more worrisome, the “old-girl network” says one LDO is closing about three units/week, usually due to inability to find staff. Perhaps they are just taking this opportunity to weed out poor performers, but I suspect something more dire is going on.
Currently, thrice weekly dialysis is the “standard.” But is it better to do more people twice weekly to accommodate staff shortages? Are there going to be waiting lists for open slots? And if so, how is equity to be maintained and by whom? Can CMS change its regulatory posture to permit changes/experiments in staffing given its current rigid “protect-the-patient by inspecting the paperwork” mindset?
For years medical organizations have feared the good old days would end with an explosive bang from Washington. But is it possible they will end with a whimper from a self-inflicted wound? Will our inability to created workplaces that are just, fair, and inviting to the workers create the changes, including the dreaded word “rationing,” we have feared for so long? I don’t know, but I think planners should be grappling with the issues now, before they get worse.
30 January 2022
 Stokes CD, Lee, TH. Confronting the Nursing Crisis by Recontextualizing its Past and Re-envisioning its Future. NEJM Catalyst, 23 November 2021. Accessed 24 November 2021 at https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0424?query=CON&c=undefined.
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