The ongoing staff shortages within the healthcare industry have brought forth a steady diet of significant challenges for healthcare leaders for not only the front line of caregivers but for all who work in the industry. Faced with the impact of the pandemic the staff within those organizations have been further taxed. The next question to focus on is whether those challenges have impacted the safe delivery of care.
Medical mishaps in the United States contribute to 250,000 deaths per year (Garcia, et al. 2019). This number does not include those patients who were injured from medical errors and continue to suffer the outcome. And finally, not reflected in the statistic is the emotional and physical toll of medical errors on the lives of the professional care deliverers who serve in all areas and specialties within the health care industry. The degree of challenges presented creates an unfortunate cycle of unrelenting stress on the care team.
Caring for the caregiver is now a priority. The healthcare workforce has only begun to recover from what will hopefully be one of the worst public health crises in their lifetime. Although proud of what has been accomplished during the past two years, the health care work force is weary.
The classic definition of burnout, as defined by Dr. Christina Maslach, “is a psychologic syndrome involving emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment”. Amongst other considerations, burnout may lead to the potential for medical errors and staff injuries to occur.
The impact of burnout for patients and staff
Determining whether burnout and stress are contributors to patient safety is an important topic to consider and an area to monitor for trends. Staff vacancies, traveler or contractor staffing, technology mishaps, a steady stream of seriously ill patients, supply chain shortages, and violence against workers adds to the possibility of burnout. There may also be an experience gap that is bringing in nurses and other direct caregivers to the bedside with less experience and training. Coupled with a shortage of all staff, some permanent staff are left with doing more with less hands-on deck.
Considering the challenges brought forth by the pandemic the issue of weary staff and patient safe practices under review currently by various accreditation bodies, patient safety organizations, and other regulatory agencies.
A recent meta-analysis of 21 different studies on this topic found a relationship between the staff performance and patient safety. They concluded that a relationship existed between high levels of burnout and worsening patient safety (Garcia, 2019).
Risk mitigation strategies may include detailed continuous onboarding of all clinical staff beyond the typical 90-day timeframe. Also included would be training on clinical practice guidelines, buddying of agency or contract staff to ensure for continuity of the orientation process, and tracking and trending of incident event data.
Well-being of others before self
The direct care team member will often put the care of others above their own care and needs and at times this philosophy may allow for the caregiver to tolerate acting out behavior longer than reasonable.
Increasing episodes of violence against caregivers has escalated with the pandemic. The degree of aggressive behavior including verbal attacks and acting out behaviors has created an environment of fear and uncertainty. Injuries to the health care worker has risen in the past two years (OSHA). Pressures from patients and their families about their plan of care, demands for off-label use of medication and a steady line of exposure to human suffering sets the stage for post-traumatic stress disorders (PTSD) layered on top of burnout.
Mitigation may include specialized training for clinical staff above and beyond what may be offered through standard means through the organization. Educate staff to OSHA safety regulations and conduct regularly occurring mock OSHA inspections/audits. Training on working with acting out behaviors for each age group and demographic of the community served is also warranted. Programs such as Workplace Violence Prevention for Nurses offer additional guidance and approaches.
The origins of staffing shortages
Even before the COVID-19 pandemic there were consistent staffing shortages of clinical staff across the healthcare continuum. The pandemic has further exacerbated staffing shortages while also creating a work environment where workers no longer feel safe.
According to the newly released ECRI (2022) annual report on the Top 10 Patient Safety Concerns, staffing shortages are the number one concern. Over the coming years, organizations can expect further shortages of nursing assistants in long-term care. With a booming aging population, the need for physicians, nurses, and assistants will steadily increase and effective solutions can prevent a crisis in care.
At the start of the pandemic in 2020, the hospital registered nurse turnover rate was at 18.7%. According to Health Care Finance, hospital turnover rate has increased by 1.7% in 2021 and currently stands at 19.5%. Cost of turn over for one bedside nurse ranges between $28,400 and $51,000.
Burnout and stress are not new symptoms for the healthcare worker, and both have been exacerbated. A recent workforce study indicated that the senior living industry lost more than 100,000 workers during the first 20 months of the pandemic, resulting in 96% of facilities and senior living communities facing staffing shortages.
The CNA-Aging Services Claim Report provided further insight noting that the lack of staffing may contribute to or exacerbate allegations of failure to monitor patients or respond promptly to change in condition.
With regards to staffing, hospitals and senior living centers will utilize both contract and/or temporary staff to supplement staffing vacancies while securing permanent staff. Additional considerations and risks arise with the increased usage of contract agency nurses. Contract nursing allows the professional nurse higher pay and flexible work schedules.
However, for the organization, constant turnover in the form of short-term, rotating contract schedules can create higher patient errors and even staff injury. The impact on hospital operational budgets is also significant. For the permanent staff, there is pay inequity as the contract agency staff are often paid at a higher hourly rate along with bonuses and other benefits.
The current state of caregiver exhaustion and burnout may be keeping the nurses away from traditional hospital and senior living settings or moving on to other industry work.
Staffing the health care system
As we ease into the first few months of 2022 and year three of the COVID-19 pandemic, the relationship between frontline workers and their employers has evolved into something unfamiliar. Employers should keep their attention and efforts on employee safety, ensuring employees feel respected and valued for the work they do, and reinforce the sense of purpose that brought these employees into health care in the first place! By focusing on these areas, employee retention can be an achievable goal.
Given the tremendous impact of the pandemic on hospitals, healthcare systems and senior living facilities, leaders are uniquely positioned to think differently about their employees’ emotional wellbeing that may have positive downstream impacts on patient care.
Employee retention is the goal, but how do we get there?
Attracting and keeping talent today requires a multifaceted approach. In a study conducted by Hall and Johnson, et al. the researchers concluded that “poor wellbeing and moderate to high levels of burnout were associated with poor patient outcomes and medical errors”. Recommendations from the study included a need for the healthcare organizations to work towards creating safer work settings, flexible work schedules and providing services and programs that support mental wellness.
The Centers for Disease Control and Prevention Strategies to Mitigate Healthcare Personnel Staffing Shortages (2022) to guide organizations during the COVID-19 pandemic:
The value of leadership presence, visibility and accessibility is notable and well-regarded by the front line. Sexton concluded that “Leadership Walkrounds” improved patient safety and fostered an environment of leadership engagement. the researchers learned that active engagement from the hospital leadership in the form of walking rounds reduced worker stress.
Second, escalating recruitment efforts will be ongoing for much longer. Ensure that the frontline is aware of the efforts being taken to secure the needed talent to bring stability to the workforce. Consider creating a web platform providing status reports on recruiting efforts and successes. Ensure that staff are offered opportunities to provide feedback about their care experiences to leadership.
And finally, another consideration for leadership is to look outside their organization for help. Healthy Nurse, Healthy Nation(HNHN GC) is a unique program developed by the American Nurse Association: “As the largest subset of health care workers, nurses are critical to America’s health care system. Nurses protect, promote, and optimize the health of their patients by preventing illness and injury, facilitating healing, and alleviating suffering. Nurses are role models, educators, and advocates. The wellbeing of nurses is fundamental to the health of our nation.”
The HNHN GC will:
The safety of healthcare workers is now paramount and a leading priority for healthcare organizations. The concern for employee safety also extends to ensuring patient safety go hand-in-hand. Work to reduce error rates and mistakes will require continued monitoring.
From the front line to senior leadership, employee safety will continue to be a high priority. In a time of uncertainty, in a place where emotions are running high, staff need to feel safe and heard. Continually escalating episodes of violence at the workplace likely will further exacerbate burnout, staffing shortages and turnover. Leadership visibility and problem-solving difficult encounters with patients provides emotional staff support.
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