© (APU GOMES/AFP/Getty Images) TOPSHOT – Registered nurse Christie Lindog works at the Cardiovascular Intensive Care Unit at Providence Cedars-Sinai Tarzana Medical Center in Tarzana, California on September 2, 2021. – According to Dr. Yadegar at the hospital, the number of covid patients are significantly less than they were in winter, but from a psychological standpoint it’s much more difficult because most of the patients in the ICU on respirators are unvaccinated, younger and healthier 30 and 40 year olds without comorbidities. Vaccinated patients at the hospital are typically older, but the Covid-19 effects are much milder compared to the unvaccinated patients that have more severe symptoms. (Photo by Apu GOMES / AFP) (Photo by APU GOMES/AFP via Getty Images)

Among the many challenges facing hospitals and health systems, none are bigger than workforce burnout. With demand for services surging, especially for an aging U.S. population, and mounting retirements of staffers increasingly stressed by work and the COVID-19 pandemic, the need for aggressive changes to be made is only increasing, according to a panel of health leaders who spoke during a recent webinar hosted by U.S. News and World Report.

“I think we were all very hopeful coming out of the pandemic that we were going to have some time to sort of reflect and recover,” said Dr. Scott Rissmiller, enterprise executive vice president and chief physician executive at Atrium Health, but “in many ways we actually across the country are in a tougher place,” he noted. “I can say we’re tired. Our teams are tired [but] there are, hopefully, better days ahead.”

Nowhere is the challenge showing up more than with nurses, the backbone of any health care system. And right now, the nation faces severe shortages, said Dr. Ernest Grant, president of the American Nurses Association. The pandemic, with the risk to baby boomers of not just being infected themselves but of carrying the virus home to their families, drove many to take early retirement, Grant said. But other drivers for the increasing nurse attrition rates preceded the pandemic and are worse now. Notably, in a recent survey of 11,000 nurses, the ANA found that 58% of respondents considered their workplace unsafe. “Two nurses are assaulted across the country every day. That’s from patients, families, or even their nurse colleagues.” Nurses want to feel safe, Grant said, but “they do not feel supported by their employer.”

Will Patterson, CEO and co-founder of CareRev, a health care staffing marketplace platform, noted how serious the attrition rate is with 2 in 5 nurses “saying they intend to leave nursing within two years.” The good news, Patterson said, is that executives are finally understanding these trends and addressing them. “Now it’s not whether we change, [but] how do we change? And how do we get there?” he said.

Dr. Erin Fraher, director of the Carolina Health Workforce Research Center at the University of North Carolina-Chapel Hill and an associate professor there, said that “one of the reasons people feel burned out is that they don’t feel valued.” She suggested reframing the issue from burnout to “how do we promote wellness at the individual level?”

“We just layered too much on top of people,” Rissmiller noted. “It’s gotten in between why they went into health care, which is to care for that person sitting in front of them.” Atrium Health, he noted, has created “what we call Best Place to Care,” an enterprise-wide initiative that focuses on three primary objectives: workflow efficiency; care provider experience and professional fulfillment; and culture and well-being. The health system has also held webinars around wellness and provides other easily accessible related resources as well as a peer support program. It also has established a “code lavender,” which enables staffers experiencing burnout, compassion fatigue or other issues to get into therapy with a behavioral health team. “We were going to focus on those things that are getting in between them [and their patients],” Rissmiller said.

Encouraging staff to report their concerns is also essential. Patterson said that CareRev collects provider feedback for health care executives, but ensures that it protects the anonymity of those sharing their thoughts. It’s important “to show the folks that have given you the feedback that you’re listening. In my career as a nurse, I felt like I was never listened to, so I think that is a big key here: listening and showing that you’re working on the problems.”

Fraher advocated a team approach to care, to help spread responsibilities around. “We know from the literature that health professionals practicing on teams … actually have lower burnout rates,” she said. “For physicians in particular, when they’re practicing on teams and can refer [a patient, for example] to a social worker for sort of complex behavioral health needs or social risk management, they feel better. Their burnout is lower because they know that the patient will be cared for.”

This approach requires “organizing the delivery of care around patient services rather than professions,” Fraher said. “We always talk about ‘How many nurses, how many doctors?’” But the real issue, she suggested, is determining what “the patient needs and what’s missing from patient care.”

She also noted the value of flexible scheduling and targeted support for providers in different life stages, such as those with young children who have child care challenges to help alleviate “emotional exhaustion,” or role changes for mid-career providers looking to develop their skills. “This is not your father’s or grandfather’s workforce anymore.” This is an on-demand workforce that needs more tailored interventions, Fraher said.

Rissmiller suggested that using virtual technology is one way to keep nurses engaged while giving them flexibility. “That has been a huge success. I think that flexibility and how we utilize the team is incredibly important for retention,” he said.

Grant emphasized the importance of focusing on retention since it is not possible to train enough new nurses to fill staffing gaps. It “all goes back to communications again,” he said. “Ask that long-term person there, ‘What keeps you here? What are some things that you’d like to see perhaps improve? What are we doing good? What are we doing bad?’ One of the things that I frequently hear all the time is, ‘You’re spending all this money on [traveling nurses]. But what are you doing to retain me here?’”

Retention may also be affected by a lack of flexibility, Patterson noted, as “a lot of the traditional employer-employee relationships, whether it’s due to unions, state laws, don’t allow for that. …That’s really where we have to rethink this entire industry. These are licensed individuals by the state. You know, we live in an age now where there’s health care benefits for independent contractors. There are tax tools. Folks have their own businesses.” His happiest days as a nurse, he noted, were “when I was an independent contractor, working for an ambulance company, because I felt like I was my own business” with the flexibility that came with it.

Switching to workplace violence, Fraher noted that the health care workforce makes up 14% of all workers but accounts for 75% of all nonfatal intentional workplace injuries. “The groups most at risk for workplace violence are nursing assistants, medical assistants, housekeeping and social workers,” she said. “A Bureau of Labor Statistics study of six years of data found that Black health care workers experienced injury rates three times greater than their white colleagues.”

She noted that “workplace violence existed before the pandemic, but the data do show from BLS that injuries that resulted in at least one day of missed work have at least doubled for workers in hospitals, ambulatory medical settings and nursing homes.”

What can be done? “I go back to the [Peter] Drucker thing: What gets reported gets managed, what gets measured gets managed,” Fraher said. “We’ve got to deal with the fact that sometimes employees don’t report.” But that data should be collected and reported, she emphasized, “so that we can more accurately assess the problem and address it.” There is some evidence that working in teams is protective to workers, she added.

Health care personnel need the same workplace protections as other industries, Rissmiller said. There is legislation being proposed, the Safety from Violence for Healthcare Employees (SAVE) Act of 2022, he noted, that would provide health care workers with protections similar to those afforded flight crews and airport workers. “We all went into health care [knowing] there were going to be long hours. We knew there was going to be heartbreak when patients had bad outcomes. We knew we were going to put our hearts and souls on the line,” Rissmiller said. “We did not think that we are going to be unsafe. We absolutely have to do everything we can, not just as health care leaders but as a nation, to protect those who are caring for us and our most vulnerable.”

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