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The Nursing Shortage in the Pandemic: Strategies to Promote a Resilient Workforce

The Nursing Shortage in the Pandemic: Strategies to Promote a Resilient Workforce

Summary

The COVID-19 pandemic served as a catalyst unlike any other to create both a labor and skills shortage in registered nurses (RNs) across the United States. There is a decreased supply of graduating nurses due to schools’ inability to accept all qualified candidates accompanied by an overall shift in RNs pursuing advanced nursing degrees. This decrease in supply is amplified by occurrences of early retirement for many nurses; over half of the nursing population is over the age of 50. As these nurses leave the workforce, they also take the skill acquired over the course of their careers. Concerns whether these impacts will negatively affect the efficacy of patient care remain in the forefront of many healthcare workers thoughts.

Introduction - Why is there a nursing shortage


The idea of a nursing shortage is not new, as the United States has experienced periodic scarcities in nursing since the 1900s. However, the current state of nurse availability has been raising voices of concern. From 2015 to 2030, more than 1 million RNs will have retired from a workforce of currently 3.8 million RNs. By the end of 2022, 500,000 seasoned RNs anticipate retiring. In addition to supply constrictions, the demand for nursing will dramatically increase. The U.S. Census Bureau reported that by 2030, the number of U.S. residents aged 65 and older is projected to be 73 million; that number is currently 54 million.

As the older generation of nurses retire, they are no longer able to pass their knowledge to up and coming nurses, leading to concern over a skills shortage. This has the potential to impact the education of new nurses, which raises alarm for the effect on patients. More than 75% of RNs believe the nursing shortage presents a major problem for the quality of their work life, the quality of patient care, and the amount of time nurses can spend with patients. In recent studies, 98% of nurses see the shortage in the future as a catalyst for increasing stress on nurses, lowering patient care quality (93%), and causing nurses to leave the profession (93%).

Decreased Supply in Graduating Nurses


Since the beginning of the pandemic, nursing schools have faced difficulty in obtaining hands-on experience for their students due to hospitals restricting access for anyone to limit the spread of germs. Hospitals began shutting down clinical rotations during COVID, unable to afford to spend valuable time and equipment on students, while simultaneously overworking veteran nurses. Some states like California decreased the number of required clinical hours after some nursing schools went fully remote.

Many schools are facing decreased aid from the government. The Centers for Medicare & Medicaid Services is reducing funding for nursing schools due to an internal error that occurred 10 years ago. The error caused for an estimated $1 billion for about 120 colleges.

Appropriate patient status determination and discharge status can also have significant financial implications for the patient. A discharge from observation status may result in a higher out-of-pocket expense to the patient compared to an inpatient discharge. Since observation status is an outpatient service, a Medicare patient pays 20% of billed charges for coinsurance.

Pursuance of Advanced Degrees


An additional reason for the lack of RNs is the rise in nurses pursuing advanced degrees. From 2010 to 2017, the increase in nurse practitioners reduced the size of the RN workforce by approximately 80,000 nurses. ,175,000 RNs per year are needed and only about 155,000 graduate per year. 28,000 RNs are becoming NPs per year. Between 2008-2016, the percent of primary care providers in rural areas that were Nurse Practitioners jumped from 17.6% to 25.2%; Urban areas grew from 15.9% to 23.0%. This gives the potential for surpluses of NPs.

Increased Occurrences of Early Retirement


The COVID-19 pandemic served as a mechanism for nurses bordering retirement to decide to leave the workforce prematurely. The American Nurses Association predicts that 500,000 seasoned RNs anticipate retiring by 2022, and the US Bureau of Labor Statistics projects more than 1 million new RNs are needed for expansion and replacement of experienced nurses. Many nurses have taken on the increased emotional burden of becoming sole support systems for patients in their dying hours, many of whom could not see their families. 67% of surveyed travel nurses responded that they felt the healthcare system did not prioritize nurses’ health and mental well-being. In Mississippi, nurses are retiring early to avoid burnout: 2,000 fewer nurses than the beginning of 2021, not to mention the 6,000 vacancies they had prior. Two-thirds of nurse’s state their experiences during the COVID-19 crisis have caused them to consider leaving nursing.  The supply of nurses is not meeting the demand, and the disparity is amplified by the fact that nursing schools cannot viably accept all qualified candidates.

Covid Impact on Nurses


As of 2021, approximately one in eight nurses had not gotten a Covid-19 vaccine nor do they plan to get one. A Texas hospital system had 153 people resign or were fired after refusing to get vaccinated. As the virus continued to spread, the American Association of Critical Care nurses conducted a survey showing two thirds of critical care nurses were considering quitting their jobs as well 67% of those surveyed were fearful of taking the virus home to their families. Nurses are reporting an overall decrease in career satisfaction in not only acute care facilities but long-term care and hospice settings as well.

Nurses have been forced to navigate through human and financial constraints, interpersonal conflict, and hostile work environments as the pandemic continued to move into its second year. This laid the foundation for nurses to leave the bedside, experience extreme burnout, mandatory overtime, and the inability to provide adequate patient care. Emotional and physical exhaustion, in addition to lack of personal accomplishment is a source of burnout which can lead to secondary trauma. Experiencing trauma leads to lack of sleep, poor appetite, job dissatisfaction and the inability to cope putting nurses at risk for post-traumatic stress disorder. Traumatic experience has been associated with having to prioritize who gets care and the high number of deaths.

Professional quality of life can be affected by both positive and negative aspects. It is not uncommon for someone to feel burnout in many aspects of life, but understanding burnout related to working in healthcare during a pandemic is very distinct. Burnout comes from the work nurses do and can manifest in very distinct ways which can have an impact on the people they are caring for. The current dynamics are 1) increased traumatic stress related to the pandemic, 2) cumulative grief with so much loss and death, 3) moral distress as nurses are having to practice differently challenging their ethics and what does not feel right.

Nurse leaders are also experiencing a high level of stress as the job demands increase and organizational constraints continue to soar. Constraints such as lack of beds, increased staffing ratios due to nurses leaving, and a large span of control. Leaders face not only patient and staff concerns but organizational constraints as well. Limited human and financial resources, interpersonal conflict, and a hostile work environment are also causes of nurse leader stress. Other concerns include the adoption of new staffing models to adapt to the shortage of nurses as well as how best to recognize nurses’ contributions to the difficulties of today’s work environment.

Strategies for building a resilient nursing workforce


Finding joy in work is rare in this current work environment which has led to job dissatisfaction, lack of employee engagement, and a sense of well-being. This is not a new problem for nursing but one that has been grossly exacerbated by the pandemic. Burnout is an occupational phenomenon and not necessarily an individual’s problem; however, individuals must be healthy and resilient to the secondary trauma that occurs as part of the work. Therefore, strategies to create a resilient workforce require both support from organizations to create healthy work environments and nurses to practice individual resilient building skills.

A healthy work environment includes adequate staffing, strong collaboration, communication, authentic leadership, recognition that is meaningful and autonomy for the staff to make their own decisions. In order to achieve a healthy work environment, organizations must empower staff, which requires transformative leadership and shared governance. Many of these elements of healthy work environments are found in Magnet organizations or units that have been designated Beacon awards – highlighting these key elements of how to achieve well-being from an organizational perspective.

In addition to workplace health, individuals must practice increasing their own compassion through personal resilience building to counterbalance the risk of burnout. Of importance to note, practicing resilience should not be done to build barriers against a poor work environment. Instead, resilience – or the ability to grow and adapt from adversity – should be done to have strength against the potential hardships that are witnessed in caregiving, such as death, loss, suffering, and pain. Personal resilience building skills can include practicing gratitude, mindfulness or meditation, journaling or debriefing through writing, or self-care, such as exercise. These activities are valuable moments to pause and reflect on the importance and significance of the work of nursing and the contribution caregivers bring to the quality of patient’s lives. In practicing resilience building activities, nurses can potentially decrease burnout and secondary stress, which can lead to a longer, more fulfilling career in nursing.

1 https://www.aacnnursing.org/news-information/fact-sheets/nursing-shortage

2 https://www.nursingworld.org/practice-policy/workforce/

3 https://www.census.gov/library/stories/2019/12/by-2030-all-baby-boomers-will-be-age-65-or-older.html

4 https://www.aacnnursing.org/news-information/fact-sheets/nursing-shortage#:~:text=Peter%20Buerhaus%20and%20colleagues%20found,nurses%20can%20spend%20with%20patients.

https://www.aacnnursing.org/news-information/fact-sheets/nursing-shortage#:~:text=Though%20AACN%20reported%20a%205.1,researchers%2C%20and%20primary%20care%20providers.

https://nypost.com/2021/10/01/nursing-programs-struggle-to-keep-up-amid-a-nationwide-shortage-of-nurses/

https://www.kff.org/wp-content/uploads/sites/2/2012/08/facultyshortagefs.pdf

8 https://www.aacnnursing.org/news-information/fact-sheets/nursing-faculty-shortage

https://www.statnews.com/2021/02/10/biden-administration-nursing-schools-pay-for-government-mistake/

10 https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2019.00686

11 https://www.businessinsider.com/travel-nurses-current-health-system-unsustainable-only-working-for-pay-2021-12

12 https://www.beckershospitalreview.com/workforce/mississippi-now-has-at-least-2-000-fewer-nurses-than-it-did-at-start-of-year.html

13 https://www.businessinsider.com/travel-nurses-current-health-system-unsustainable-only-working-for-pay-2021-12

14 https://www.businessinsider.com/nurses-havent-gotten-covid-19-vaccine-causing-staff-shortages-2021-8

15 https://www.washingtonpost.com/health/2021/06/22/houston-methodist-loses-153-employees-vaccine-mandate/


Navigating Observation Level of Care & Appropriate Patient Status Determination

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Outpatient Observation Management – Impact on Financial Cost & Best Practices

Placing a patient in the most appropriate level of care is important to ensure the patient is cared for with the right level of services and the hospital is reimbursed appropriately for services rendered. However, many hospitals are challenged by the status determination process, and often over utilize the observation level of care. According to publicly available Medicare data, the national average observation rate (the ratio of bedded observation to inpatient cases) was 18% in 2019. The state average observation rate for Illinois facilities in the same period was 25%. This means that most short-term acute care facilities in Illinois had an observation rate that exceeded the national average (Figure 1). There are considerable financial implications to patient discharge status, which often results in missed revenue. Hospitals and health systems should consider implementing status determination process improvements to augment net patient revenue while prioritizing patient outcomes.

Figure 1: Traditional Medicare Observation Rates for Illinois short term acute care facilities

Traditional Medicare Observation Rates for Illinois Scale

Source: Publicly available Medicare data. Represents Traditional Medicare only.

Observation Status and Medical Necessity


Observation status is an outpatient designation that allows providers to place a patient in an acute care setting to monitor the need for an inpatient admission. Common signs and symptoms including chest pain, shortness of breath, nausea/vomiting/stomach pain and fever might result in placement in observation for further testing. Appropriate observation patients typically have much lower acuity and severity of illness compared to inpatient level of care, and are commonly discharged from the facility in observation status within 24-36 hours.

A bedded observation patient can also be appropriately converted to inpatient status if there is evidence of medically necessary care. “Medical necessity”, the principle defined by CMS and other payors, establishes the distinction and substantiating evidence between observation and inpatient levels of care. Medical necessity is documented within the medical record, and should clearly and precisely illustrate the complexity of medical factors and the reasoning for the required inpatient admission (Figure 2). Inadequate documentation can result in payor denial for inpatient authorization and refusal of payment for services delivered. Physician documentation is the cornerstone for appropriate status determination, and there can be significant financial implications to the chosen level of care.

Figure 2: Example of How Appropriate Medical Necessity Documentation Can Support an Inpatient Admission

Observation Appropriate

  • Patient complaint of shortness of breath
  • Abnormal labs
  • Vital signs stable
  • Will need to monitor
  • Consult Nephrology and cardiology

Inpatient Appropriate

  • Patient complaint of shortness of breath with imaging findings of new onset of congested heart failure
  • Lasix 80mg IV given
  • Oxygen saturation 87% on room air, improved to 100% ounce on 4L ofO2
  • Abnormal renal function consider, acute kidney injury
  • Will need cardiology and nephrology consulted
  • Patient appropriate for inpatient level of care anticipate 2 midnight stay

Financial Implications of Observation Management


Delivery of care and outcomes are the priority. But appropriate patient status and level of care determination can significantly affect net revenue. Payor reimbursement (for both government and private payors) typically differs considerably between observation and inpatient status. While the nuances of payor agreements may vary across payors and facilities, reimbursements for observation discharges are often lower than inpatient payments While this reimbursement differential can vary, a typical Traditional Medicare case can provide an illustrative example. CMS IPPS and OPPS final rules stipulates that a standard inpatient case is reimbursed approximately $6,500, while a standard observation discharge is reimbursed approximately $2,000. In this example, there is approximately a $4,500 reimbursement variance for a case that might have received the exact same care, but was discharged in an inappropriate status. This positive reimbursement variance is similarly prevalent with other government and private payors. Across most payors, documentation of medical necessity and deliberate processes for status determination can have a significant impact on net patient revenue.

Appropriate patient status determination and discharge status can also have significant financial implications for the patient. A discharge from observation status may result in a higher out-of-pocket expense to the patient compared to an inpatient discharge. Since observation status is an outpatient service, a Medicare patient pays 20% of billed charges for coinsurance.

Observation Management Best Practices


There are several ways that a facility can align care delivery and revenue cycle functions through level of care and status determination processes.

Care Team Collaboration
Collaboration and communication among the care team members (providers, utilization management, and nursing staff) is critical to a successful observation management program. This includes deliberate discussions regarding patient needs and plan of care between care teams. This also includes documentation within the medical record that clearly substantiates the medical necessity. A dedicated huddle to focus on observation patients also enables communication and collaboration. This observation huddle serves as a forum for Case Management, Utilization Management and Physician Advisors to review all observation patients at least once per day and is an effective method to highlight any barriers to discharge, necessary follow-up actions, and status conversion potential.

Status Determination at the Portal of Entry
Appropriate status determination from the Emergency Department reduces the need for conversion to an inpatient status later in the stay and helps place the patient in an appropriate care setting. Facilities with leading patient status processes dedicate Case Management/Utilization Management staff in the emergency department to own the initial status determination process. These staff should be integrated into a collaborative process between ED providers and hospitalists that focuses on effective communication, accurate initial medical necessity reviews, and timely provider documentation of patient needs and acuity.

Utilization of Observation Units
When observation cases are bedded on inpatient units, care teams often have difficulty differentiating between patients placed in observation status or inpatient status. This results in longer lengths of stay for observation cases, and increased resource utilization for observation care. A hospital can delineate patient status assignments by implementing a unit focused exclusively on observation patients. Sometimes these units are within or adjacent to emergency departments. This enables the care team to automatically differentiate observation patients from other bedded patients. It also allows for increased monitoring of observation patients (recommended rounding 3x per day vs 1x per day). Sometimes facilities will introduce diagnosis-specific algorithms to aid in this colocation process, including chief complaints such as chest pain, syncope and collapse, heart disease, cellulitis, and headaches. If a dedicated observation unit is not possible, providers and transfer centers should attempt to cohort observation patients as much as possible.

Physician Advisor Integration
A sophisticated Physician Advisor (PA) program utilizes the PA resource as an engaging liaison between Case Management, Utilization Management, providers, and administration. The PA can aid in the status determination process through secondary review of the observation cases, and can assist the UM team and providers through the documentation process. The PA may also be involved in additional processes including payor appeals, denials management, education for providers, and other quality improvement efforts.