Unfiltered online repositories such as review sites and social media can contain valuable patient feedback, researchers said.
U.S. counties with healthcare facilities with the greatest share of 1-star Yelp reviews had the highest death rates, and a difference of just one point—roughly one star—between counties’ average scores could indicate a mortality rate that is better or worse by dozens of lives, according to researchers at the Penn Medicine Center for Digital Health.
Yelp is a review website that uses a five-star rating system to evaluate businesses, with one start rating the lowest and five stars rating the highest.
"Many of the facilities that provide essential care may not otherwise have standardized measures or approaches to collect data about patients’ experience of care. This is a missed opportunity," the study’s senior author, Raina Merchant, MD, director of the Center for Digital Health and a professor of emergency medicine in the Perelman School of Medicine at the University of Pennsylvania, said in a press release.
"Much of the focus in healthcare is on quality and outcomes," she said. "Patient experience is also critically important and should be factored into how to improve care across the board. This appears to be one novel data source for doing that."
More than 95,000 facilities that provided some form of care recognized by the Affordable Care Act were included in the study led by Merchant and its lead author, Daniel Stokes, MD, a researcher with the Center for Digital Health and an internal medicine resident at UCLA Health.
Each facility included in the study had at least three reviews between 2015 and 2019 on Yelp. Each healthcare facility’s ratings were also coded to the specific U.S. where it was located, resulting in more than 1,300 counties—roughly a third of the country—being represented in the study.
Overall, healthcare facilities achieved an average 2.9 score out of 5 stars, but reviews were weighted very heavily to either side of the scale: five-star reviews account for 52.9% of all reviews, while one-stars made up 33.3%.
But when researchers looked at the county-level data of reviews, they found that five-star reviews within the group with the lowest death rates made up 55.6 percent of their total, while one-star reviews were at just 29.1 percent. In the group of counties with the highest death rates, five-star reviews made up only 42.9 percent of the total, compared to 38.8 percent one-stars.
The researchers then determined that if a county’s health facilities’ reviews were a star higher than their average—one point on the scale—models indicated that it translated to 18 fewer deaths per 100,000 residents. But when the study was refined to include counties with three or more healthcare facilities, the impact was greater, indicating a reduction in roughly 53 deaths per 100,000. Refined even further to counties with five healthcare facilities or more, the impact grew to about 60 preventable deaths.
Yelp reviews provide narratives, which was particularly useful to the study. The researchers used natural language processing algorithms to gain special, categorical insights. They showed that the types of words most associated with one-star reviews related to time [such as "hours" and "waiting"], payment ["money" and "pay"] and interpersonal interactions ["rude" and "told"].
Common language in five-star reviews changed depending on location. In high-mortality counties, "friendly," "nice," and "staff" were all typical, while low-mortality counties were associated with "Dr.," "helpful," "question," and "pain."
The researchers believe their work, published this week in the JAMA Network Open, adds evidence that unfiltered online repositories like review sites and social media contain valuable patient feedback and are an untapped resource for informing healthcare providers about what they do.
"Online reviews of healthcare facilities provide direct insight into patients' experiences of care and can be a powerful force in shaping the care we provide to be more patient-centered," Stokes said. "This has important implications for both individual and community health."
'The pandemic has created a perfect storm of increasing expenses and decreasing revenues,' managing director says.
Bold, new thinking is needed in nearly every area of U.S. hospital and health systems' operations to counteract COVID-19's continued undermining of their performance improvement efforts, experts say.
Transformative change is needed in access to care; supply chain management; patient throughput, or the efficient flow of patients; workforce optimization and engagement; service line enhancement or rationalization; and revenue cycle, according to Kaufman Hall’s 2021 Healthcare Performance Improvement Report.
Labor and supply chain challenges are continuing to drive hospital and health system costs higher at the same time revenues are lower due to concerns over patient volume, the report found.
For example:
100% of respondents said they faced staff burnout, difficulty filling vacancies, wage inflation, and high turnover rates.
92% said it is difficult to attract and retain support staff
88% have increased base salaries.
65% are dealing with high turnover among clinical staff
73% are dealing with wage inflation
99% of survey respondents experienced challenges in supply procurement, including shortages of key items and significant price increases.
Hospital leadership must rethink their approach to performance improvement, which will require revisiting the premise that not-for-profit hospitals and health systems can lower their costs while maintaining control over all aspects of operations, the report said.
"The pandemic has created a perfect storm of increasing expenses and decreasing revenues," Lance Robinson, Kaufman Hall managing director who leads the firm's performance improvement practice, said in a press release.
"For most institutions, navigating today's financial and operational challenges and positioning for future growth requires radical change that is achieved only with new thinking and partnerships," he said. "Now more than ever, hospitals need to build relationships with physician groups, insurers, retailers, vendors, and other providers. It's increasingly apparent that most organizations don't have the resources they need to evolve on their own."
The report's other notable findings include:
Volumes in many service lines remain well below pre-pandemic levels. While cardiology and cardiovascular services have seen the most significant rebound, just 44% of respondents in these services have seen a return to pre-pandemic levels. Pediatrics has been particularly hard hit; only 22% of respondents say pediatric volumes have recovered to pre-pandemic levels, and 16% say that pediatric volumes remain below 75% of pre-pandemic levels.
The pandemic is prompting potentially permanent changes to the workforce. Only 23% of respondents say they expect the ratio of administrative staff working remotely is to return to pre-pandemic levels, while 66% said that the number of staff working remotely will stay at the level experienced during the pandemic, while another 11% say they expect that the number to increase.
More than half of respondents (52%) say the pandemic has driven their organization to adopt new processes, positions, or departments that will be continued going forward.
Seventy-five percent of respondents have experienced adverse revenue cycle impacts during the pandemic, including a higher percentage of Medicaid patients and increased rates of insurance denial.
The annual Kaufman Hall State of Healthcare Performance Improvement Report analyzes the performance improvement and cost transformation efforts of hospitals and health systems. Results are based on survey responses from 73 hospital and health system leaders nationwide, including representatives from all regions of the country as well as from urban, suburban, and rural markets.
Without appropriate trauma support, nurses will continue to flee the profession, researcher says.
Nurses are struggling so much with their own psychological stress and trauma from the harsh effects of the COVID-19 pandemic and the conditions it has caused, that their hospitals and health systems must provide the necessary support to heal, a trauma researcher says.
But they can't do it alone.
Leaders are called upon to step up and to really be aware of this, to familiarize themselves with the literature on being trauma-informed individually as a leader, as well having an organization be trauma-informed," says Karen J. Foli, PhD, RN, FAAN, an associate professor and director of the PhD in Nursing program at Purdue University School of Nursing.
Providing a supportive environment
While it is critical for traumatized nurses to recover and establish resiliency, doing so requires support by hospitals and health systems, Foli says.
"There's such a drive right now … to cultivate nurses being resilient individuals, and that isn't necessarily wrong, but it is not the complete picture," Foli says. "For a nurse to be resilient, she or he has to have an environment that will support not only establishing resiliency, but the maintenance of resiliency. But when you have conditions that are ripe for psychological distress and or trauma, resiliency is very hard to cultivate."
For nurse and hospital leaders to help their nurses handle and heal from trauma, they must create a trauma-informed culture.
A trauma-informed program, system, or person has a knowledge and understanding of trauma and its far-reaching effects, which, in some nurses is caused by seeing patients die; tending to patients who can't get relief from symptoms; patient and family aggression; feeling overextended because of inadequate nurse-to-patient ratios; frustration; and helplessness, according to the study, Secondary Posttraumatic Stress and Nurses’ Emotional Responses to Patient’s Trauma published in the April/May 2017 issue of Journal of Trauma Nursing.
"In terms of mental health resources, it's not a one-and-done thing," Foli says. "I spoke at Kaiser Permanente a couple of years ago, pre-pandemic, and nurses were saying, 'You know, it's great to have a quiet room, it's great to have aromatherapy, but it's not enough.' If you have a cumulative distressing environment where there are few resources or little awareness of what's going on and what nurses are experiencing, you're going to have these nurses leave the workforce and that's what we're seeing."
Indeed, 22% of nurses indicated in a recent McKinsey survey that they are considering leaving their current position of providing direct patient care.
Of that 22%, some 60% said they were more likely to leave since the pandemic began because of such factors as insufficient staffing, workload, and the emotional toll, according to the survey.
Creating a trauma-informed environment
Creating a trauma-informed environment begins by asking the right questions and listening, Foli says.
"[Leaders] have to be trauma-informed in what they ask," Foli says. "For example, one of the ways to find out what's going on is to ask, "What happened to you?" versus "What is wrong with you?" There's a big difference in how we phrase those two questions, with the latter inferring that it's more or less your fault."
If hospitals and health systems don't address trauma, nurses will continue to leave the profession in droves, further contributing to the worsening staffing shortage, Foli says.
"Resiliency is a very complicated concept and if you look at the literature, some would argue that there's perhaps a familial or even a genetic predisposition for some of us to be resilient," she says. "But regardless, when you talk about nurse resiliency, again, it puts the burden or the responsibility on the individual nurse when in fact, the whole organization really needs to look at what they can do to support resiliency."
The 3 'E's' of trauma
Unaddressed trauma can significantly increase the risk of mental and substance use disorders, along with chronic physical diseases, but with proper support and intervention, people can overcome traumatic experiences, according to the Substance Abuse and Mental Health Services Administration (SAMHSA)—the agency within the U.S. Department of Health and Human Services with the mission to reduce the impact of mental illness and substance abuse.
To provide a framework for treating trauma, SAMHSA created a concept it calls The Three 'E's" of Trauma:
Events—Circumstances that may include the threat of physical or psychological harm. These could include violence, natural disasters, or pandemics. Such events may occur once or repeatedly over time.
Experience—An individual’s experience of these events determines whether it is a traumatic event. A particular event may be traumatic for one, but not for another.
Effects—Long-lasting adverse effects of the event are a critical component of trauma. Effects may begin immediately or be delayed, and the duration can be short- or long-term.
"If there was ever an organization that included trauma, with or without a pandemic, it's a healthcare organization," Foli says. "Your patients are in crisis because they're there for life-threatening or life-saving treatments [and] we as nurses, who are rendering care to these vulnerable individuals through our empathy and our caring, co-exist and co-live that trauma with them. Nurses that have that empathetic caring nature will have that secondary traumatic stress, so it's in the air we breathe."
But understanding trauma is not enough to successfully treat it, according to SAMHSA, so it created a trauma-informed approach, which is based on a set of four assumptions and six key principles.
The four assumptions—also known as "The 4 R's"—are described by SAMHSA in this way: "A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization."
SAMHSA's six key principles of a trauma-informed approach are:
Safety
Trustworthiness and transparency
Peer support
Collaboration and mutuality
Empowerment, voice, and choice
Cultural, historical, and gender issues
"It's really a time of upheaval in the nursing profession," Foli says. "There are ways we can make it better for nurses, but until there's this awareness that these environments are ripe for trauma and that their support have to be given to nurses as professionals, then we will come up short."
The best ways are for leadership to 'listen, to be present, and not assume that we know what the staff wants or needs,' CNO says.
Resilience is a blend of individual responsibility—coping adaptively, having knowledge of self, and accepting limitations—along with support provided by others, according to one nursing study.
Hospitals and health systems should foster nurses' resilience by integrating support and education—not only to help them successfully cope with their high-stress job, but to provide high-quality care, the study says.
Mary Jo Loughlin, who recently was named chief nursing officer and senior vice president of patient care services for Hunterdon Medical Center in Flemington, New Jersey, places high priority on cultivating resilience in her nursing staff.
HealthLeaders spoke to Loughlin about how Hunterdon continues to build resiliency for its nurses.
This transcript has been lightly edited for length and clarity.
HealthLeaders: Why is resiliency important in a nurse?
Mary Jo Loughlin: Because nurses give so much to other people and if they don't care for themselves, they're not able to then provide that care to others, whether it's patients or their co-workers. Nurses are stretched so often, like a rubber band, because of the role we're in, and you need to be able to bounce back, and the ability to do that will reflect on whether you're going to be successful in a nursing career.
It's emotionally and physically draining to be at the bedside, to be a nurse, and it's challenging to not let it get to you. And you need to be able to find different outlets so you can bounce back and be able to care for yourself, the patients and their families, and your co-workers. You're also caring for your family on the outside and you're giving, giving, giving and you're pulled in so many different directions, so it's imperative that you not be stretched so thin and have a moment for yourself.
HL: What are some examples of nurses who have been particularly resilient during this pandemic and why they managed to do so well?
Loughlin: The two that come to mind are on our COVID unit. There was a nurse who had an artistic background—photographs were her thing—and she had brought in a lot of her work. If you think about the height of COVID, the units look like war zones, with PPE (personal protection equipment) everywhere, there are all these carts in the hallways, the doors are shut, and there's nothing pretty. This nurse brought in her artwork and had all over the unit, along with fresh flowers that she worked with a local shop to have for the unit, so there was something pretty to look at.
The second is [during a COVID surge] when we turned a med/surg unit into a second ICU and there was a nurse there that utilized tiered nursing [where non-ICU nurses augment the trained and experienced ICU nurses]. She created this environment that was positive even though people were scared because they are not critical care nurses [but] they became a critical care unit. They were using baby monitors to monitor the patients because that unit was not equipped as a traditional ICU.
She really embraced and partnered nurses together [based on] skill sets that each one of them had to be able to support one another, so everyone felt like they were in it together. That unit, because of her, is more resilient than some of the other units because they really embraced that team and caring for each other by doing a tiered approach to patient care.
HL: How different is resiliency during the pandemic than from before the pandemic?
Loughlin: Over the history of being a nurse, burnout happens and people feel like days are tough and it's hard sometimes to bounce back. The difference with the pandemic is staffs are seeing no end because it's not going away. There's fear about the vaccine and people who aren't getting vaccinated in the community and some of it's becoming political and that's what's making it different for the staff.
You can't get away from it outside of work because it's in your home, it's in worrying about whether you're going to the store or church or whatever it is. So normally prior to a pandemic, you're just dealing with those challenges and fatigue while you're at work and now with the pandemic, you can't get away from it.
HL: What are some of the roadblocks to nurse resilience?
Loughlin: Staffing. During the pandemic when everything shut down, we had enough staff because we weren't doing elective surgeries, physical therapy was shut down, and there were more staff than patients. Primary care physician offices were closed, and everybody was deployed to the hospital.
Coming out of the initial surge of the pandemic, we lost a lot of nurses to retirement, so that's adding to the shortage, and then you have the younger nurses who think this is not exactly what they went in it for and didn't have the best experience. You've got both of those things, post-pandemic, playing into staffing shortages.
The staffing issues are beyond what any of us could have ever expected and it's not just the nurses, it's ancillary help, patient care assistants, and transport. Now that the pandemic is "over," which it's not, we're picking up the pieces and wondering how we're going to find staff [and] figuring how we're going to provide care in a different way. It's the new norm.
HL: What are some of the most successful resilience strategies that you've been a part of?
Loughlin: The biggest thing is having leadership listen, to be present, and not assume that we know what the staff wants or needs. If you know your staff and you know the culture, you can tell when people are getting [stressed out] and they may not even recognize it in themselves. Our strategies have been to help them recognize that they're getting to the point where they're getting stretched too thin and need some assistance.
We have connected our staff with Schwartz Rounds [conversations with nurses and other staff about the emotional impact of their work] and we offer EAP [employee assistance program] services. One of the things that has been the most effective is we trained for Stress First Aid [which teaches individuals how to identify stress in others or themselves].
Other things we've done are simple but make people feel appreciated and valued. All units have hydration stations for the self-care component of resiliency. These stations also have things like mints, lip balms, skin protectors, and mask extenders.
We have what we call "Zen Dens," which is a room with a chair that gives a full body massage and it's quiet in there with dim lighting, aromatherapy, and music therapy, and staff can take five minutes and go in and just chill. We've done videos on burnout, self-care, spiritual resilience, and seeking help through EAP.
HL: What are some of the differences in building resiliency in new nurses versus older, more-experienced nurses?
Loughlin: The generations all want and need different things. How you recognize them is different; some people want in-person, one-on-one [conversations], while some people like texts. Generations have different needs of what recharges their battery and what makes them more resilient and able to face the challenges.
The newer nurses value time off; they know how to unplug a little better. They're also better at asking for help. The more seasoned nurses feel like they shouldn't be asking for help and that they should be resilient. You have to identify and monitor those individuals differently because they're not going to present the same way.
The older nurses have been through it, like myself; we've been through AIDS and bounced back from Ebola and other challenges in healthcare. We've gotten more used to it and have figured out ways to recharge our batteries. The younger nurses know how to do it on the outside but are having difficulty thinking that it's going to get better because they haven't been through challenges and seen that it does get better. It ebbs and flows; the pendulum swings back and forth.
The trend is likely to continue into 2022, as patient acuity in both COVID-19 and non-COVID cases rises, new report says.
An ongoing shortage of hospital workers, particularly nurses, caused by the surge of the Delta variant, will place additional strain on not-for-profit hospitals' profitability in the long run, says a new report released by Moody's Investors Service.
Some hospitals have lost revenue by suspended elective overnight surgeries due to COVID cases and insufficient staffing, the report says.
"Over the next year, we expect margins to decline given wage inflation, use of expensive nursing agencies, increased recruitment and retention efforts, and expanded benefit packages that include more behavioral health services and offerings such as childcare," the report says. "Even after the pandemic, competition for labor is likely to continue as the population ages—a key social risk—and demand for services increases."
After a short reprieve, expensive contract labor for nursing has increased as COVID-19 cases have risen with the Delta variant, and in some cases, to a higher level than during the surge seen in mid-2020, some hospitals report. The use of traveling nurses has further driven up the demand and cost of contract labor.
This trend is likely to continue for the remainder of 2021 and into 2022, especially as patient acuity related to both COVID-19 and non-pandemic cases rises, requiring more advanced care, the report says.
The nursing shortage will be intensified as employees leave because of burnout, taking care of family, contract labor opportunities, refusing to take the COVID-19 vaccine, or retirement.
Moody's predicts the worker shortage may provide opportunities for unionization or lead to more difficult negotiations with unions over the near term, which will contribute to higher expenses.
Though salaries and benefits generally exceed half of any hospital's expense base, this percentage is likely to rise over the near term as hospitals increase budgets to cover recruitment and retention costs. Many hospitals report an increase in minimum wage for non-clinical workers to compete with other employers in service sectors. This has led to wage inflation as other salaries within a hospital must be raised to avoid salary compression.
Enrollment in undergraduate nursing school programs increased 5.6% in 2020, according to the American Association of the Colleges of Nursing, indicating a more robust long-term staffing pipeline.
Hospitals and health systems are working with local schools, as they did pre-pandemic, to increase faculty members, expand class sizes, and create scholarship opportunities.
Until there is a more sufficient nursing supply in hand, however, hospitals and health systems will seek various methods to attract staff and keep staff, such as signing bonuses in exchange for a multiyear commitment; retention bonuses to keep existing staff; establishing internal float pools to defray the expense of agency and temporary nurses; and recruiting from other countries, the report says.
Employers project health benefit costs will jump more than 5% in 2022, new survey finds.
Though health benefit costs are expected to increase by more than 5% in 2022, U.S. employers are prioritizing healthcare affordability and employee well-being over the next two years, according to a new survey by Willis Towers Watson, a global advisory, broking, and solutions company.
Despite cost management initiatives, employers expect their costs for medical and pharmacy benefit expenses to increase 5.2% in 2022, which is slightly lower than the 5.5% increase employers projected for 2021 but sharply higher than the actual 2.1% increase in 2020.
Last year’s increase—the smallest in decades—is considered an irregularity because many people deferred non-emergency healthcare during the pandemic and embraced telemedicine.
The total average employer cost, including premiums, is expected to rise from $12,501 per employee in 2020 to an estimated $13,360 in 2021. Employee contributions for premiums will increase slightly, from $3,269 in 2020 to $3,331 in 2021.
A total of 378 survey respondents who employ 5.9 million workers were asked to identify their key priorities over the next two years:
Achieve affordable and sustainable costs for organization: 90%
Achieve affordable costs for employees, especially lower-wage employees: 86%
Enhance employee well-being: 85%
Identify programs that support diversity, equity, and inclusion goals and social determinants of health: 78%
"Rising costs and increased utilization fueled by a resurgence in deferred care are driving employers to find new ways to control costs while providing employees with affordable, high-quality care," Julie Stone, managing director, health and benefits, Willis Towers Watson, said in a press release.
"COVID-19 accelerated both provider adoption and employee acceptance of telemedicine and virtual care. Employers see continued use of virtual care as integral to sustaining improvements made in access, quality and cost management," she said. "At the same time, employers must now address the Delta variant, encouraging workers to access the care and support they need while grappling with rapidly evolving conditions."
The survey identified several measures employers are taking to address affordability, benefit designs, and network management issues, including:
Premium contributions based on pay and grade: Nearly one-fourth of employers (22%) structure employee contributions based on pay levels or job grades. Another 8% are planning or considering doing so in the next two years.
Working spouse surcharges: One-fourth of employers (25%) use spousal surcharges when additional employer coverage is available for the working spouse. Another 9% are planning or considering spousal charges in the next two years.
Narrow networks: Nearly one-third (30%) of employers are planning or considering offering a narrow network of higher-quality and/or lower-cost providers. Currently, two in 10 respondents (21%) offer narrow networks.
Centers of excellence: Nearly one-half of employers (48%) use centers of excellence within their health plans. Another 23% are considering doing so.
Concierge services: About one-third (31%) offer access to concierge services with integrated care management programs; 25% are planning or considering doing so.
Telebehavioral health: Most employers (89%) are offering coverage for telebehavioral health services, and 7% are considering it.
Onsite health promotions: More than one-half of employers (55%) offer onsite/worksite health promotion activities, and 17% are considering it.
Specialty drugs: More than one-half (54%) evaluate specialty drug costs and utilization performance through the medical benefit, and another 29% are considering it.
"As employers update their ways of working, they are finding a challenging environment to attract and retain employees," said Jeff Levin-Scherz, MD, Willis Towers Watson's population health leader.
"Those employers that take action to keep their healthcare benefits affordable and easily accessible, strengthen the well-being of their workers and build a better employee experience will gain advantages in the future—namely, a more healthy, satisfied and productive workforce."
Education programs are not obligated to provide alternate clinical experiences based on a student’s vaccine preference, new policy issued by leading nursing organizations says.
Nursing education programs are not obligated to provide alternate clinical experiences requested by unvaccinated nursing students when the designated clinical facility mandates the COVID-19 vaccine, according to a new policy issued by the National Council of State Boards of Nursing (NCSBN).
The NCSBN and eight other leading nursing organizations, including the American Organization for Nursing Leadership (AONL) and the American Nurses Association (ANA), issued a policy brief to provide guidance to boards of nursing and nursing education programs receiving requests from students for alternate clinical experiences when a program’s clinical sites require the COVID-19 vaccine.
Nursing education programs are mandated by boards of nursing as well as accreditors to provide students with clinical experiences, but they are not obligated to provide substitute or alternate clinical experiences based on a student’s request or vaccine preference, the policy states.
"As nurse leaders we wanted to provide direction to nursing programs that are dealing with a small number of unvaccinated students," Maryann Alexander, PhD, RN, FAAN, the national council's chief officer, nursing regulation, said in a press release. "Clinical experiences are crucial to nursing education and simulation, while extremely valuable, cannot completely replace direct care experience.
The policy brief recommends that nursing programs reach out to vaccine-hesitant students and counsel them about the benefits of the vaccine and dispel myths and misinformation students may have.
If the academic institution mandates the vaccine, students can refuse it. However, if they are not entitled to a reasonable accommodation under the disability laws or for a sincerely held religious belief, then the student may be disenrolled from the institution or nursing program or may not be able to fulfill the clinical requirements of the program, resulting in them not graduating.
"We know that vaccination protects both the person vaccinated and those for whom they care," Alexander said. "Our hope is that unvaccinated nursing students follow the science and get the COVID-19 vaccine."
Unless pressure on healthcare facilities and workers eases, 'our health system is in peril,' AACN president warns.
The American Association of Critical-Care Nurses (AACN) has launched Hear Us Out, a nationwide effort to show the COVID-19 pandemic from frontline nurses' perspective and urge those who have yet to be vaccinated to reconsider.
"COVID kills, and the death is a difficult, tragic, and lonely one," she says. "By engaging in an honest dialogue, we hope to help Americans understand the consequences of what is now a preventable disease."
The sustained and extreme demands of caring for hospitalized, largely unvaccinated, patients are taking their toll. A recent AACN survey of more than 6,000 acute and critical care nurses revealed:
92% of nurses surveyed said they believe the pandemic has depleted nurses at their hospitals and, as a result, their careers will be shorter than they intended
66% feel their experiences during the pandemic have caused them to consider leaving nursing
76% say that people who have yet to be vaccinated threaten nurses' physical and mental well-being
But unvaccinated adults have concerns about the COVID-19 vaccines and share many of the same reasons for rejecting the shot, according to a Kaiser Family Foundation survey.
Newness of COVID-19 vaccines (53%) and worries about side effects (53%) are the main reasons, says the KFF survey. Other major reasons include simply not wanting to get the vaccine (43%), thinking they do not need the vaccine (38%), not trusting the government (38%), not believing COVID-19 vaccines are safe (37%), and not trusting vaccines in general (26%).
HealthLeaders spoke with Wathen about the AACN's efforts to change the minds of nearly 23% of Americans who have not received at least one dose of the COVID-19 vaccine.
This transcript has been edited for clarity and brevity.
HealthLeaders: What does the AACN hope to accomplish with this new campaign?
Beth Wathen: We're worried about our nursing workforce. We're worried about the stability of our healthcare system if nurses and others continue to leave. And we're worried that many more lives will be lost if we don't do everything we can.
As the leading professional voice of acute and critical care nurses, AACN has been advocating for the wellbeing of frontline nurses since the start of the pandemic, partnering with policymakers and other professional organizations, but honestly, as we saw Delta surging and ICU volumes skyrocketing, we realized the situation called for a different approach—a public-facing effort above and beyond how we might normally respond.
HL: How cognizant do you really think the public is about the toll the pandemic is taking on nurses and healthcare workers?
Wathen: I don't think they understand the depth of the toll and burden on frontline healthcare workers, and that's part of our message. Our health system is in peril. Nurses are leaving in record numbers and if the health system falters because we don't have enough nurses to care for patients, lives will continue to be lost long after this pandemic and that's a message we really want the public to understand.
This is more than just COVID. We already are hearing stories about health systems that are already at their brink, that can no longer provide care to patients with heart attacks or cancer or any other reason that you might need care.
HL: What are some of the tools in the Hear Us Out toolkit?
Wathen: The toolkit will contain materials that will help to empower and educate vaccinated members of our community on how to have constructive, nonjudgmental conversations with those in their circle—their family and friends who are not yet vaccinated.
It's about building trust, and [asking,] how do we have those conversations? We have to listen; we have to be nonjudgmental; we have to make it safe, build trust, and stay the course. Recent research showed that those who have yet to be vaccinated sometimes fear social death more than physical death itself, so that means we need a different approach to how to have these conversations and … try to understand where their concerns and hesitancies lie.
The toolkit will also include information on the rigorous testing and evaluation of the vaccine because we know that's been a source of questions for people. Finally, it will include nurse stories. It's important that our broader community truly understands what it's like to have COVID, to be in the ICU, to see people dying—young, previously healthy people—from COVID. Our intent is to paint of picture of what that reality is like and partner with our community to help us to change minds and save lives.
HL: Regarding the vaccine, lines have been drawn in the sand between employers and employees, between friends, and among family members. What are some techniques that Hear Us Out offers that can begin to erase some of those lines?
Wathen: First and foremost, the campaign is completely apolitical and aims to talk about what it's like to live and die from COVID from everyday people on the front lines. There may be people out there that will never change their mind but there's a lot of people out there that still have some questions and we can turn that tide through open honest dialogues, through answering questions, through not judging, and not making assumptions about people.
This is beyond just COVID; this is our ability to provide care. We already know what's happening in certain parts of the country, where people are having to be flown out of state hundreds of miles away just to get care for other illnesses. It's absolutely [imperative] for the general public to understand what's at stake here.
HL: An American Nurses Association survey indicates about 90% of nurses have been vaccinated, leaving 10% who have not. They have witnessed the deaths and the trauma of COVID-19. How can Hear Us Out change their minds?
Wathen: Like the general public, healthcare providers can also benefit from this campaign by seeing different points of view and seeing firsthand how hospitalizations of unvaccinated Americans are impacting their peers. Nurses or other healthcare providers can absolutely have questions or concerns around the vaccine [and] if I have a colleague who has not had a vaccine, I'm going to sit down and try to understand where the concerns lie and how I can help clarify, answer questions, listen, [and] have that dialog to see what's holding them back.
[I would ask them to] think about your circle. Think about who you'd like to protect by helping to bring an end to this pandemic. I want to get to the day when I can hold my brand-new grandbaby inside without a mask or visit my mom who is 94 years old without worrying I'm putting her at risk.
Think about how we can protect those people in our individual circles, because this is not just about individuals anymore. This is about understanding that our individual actions impact others and so this is our call to action. This is our request to partner with the public, to partner with our healthcare colleagues to do our part to help bring an end to this pandemic.
New Press Ganey flight risk assessment finds decreased engagement ratings are driving nurse turnover possibilities.
Nearly 30% of RNs are at risk of leaving their organization and millennial nurses are most likely to quit, according to a new national analysis by Press Ganey.
A recently conducted national Flight Risk Analytics assessment analyzing responses from 100,000 healthcare employees revealed a generational divide, leading factors shaping turnover risk, and low levels of engagement among front-line caregivers.
The study also revealed several trends, including:
New hires who don’t have a connection with their team, managers, or organization are at the greatest risk for turnover. About one in five nurses who fits this profile leaves their job.
Employee engagement ratings dropped at twice the rate among RNs compared with non-RNs in the past 12 months.
Shift schedules play a significant role in employee engagement: Nurses who work night and weekend shifts reported lower levels of engagement than their day-shift counterparts.
"Disconnection isn’t the diagnosis—it’s a symptom of a larger caregiver crisis that transcends turnover and retention," Jeff Doucette, DNP, RN, NEA-BC, FACHE, FAAN, Press Ganey chief nursing officer, said in a press release. "The consequences of a critical shortage of early career nurses could reshape our healthcare infrastructure for generations to follow,"
The analysis shows promising results for spotting turnover risk and understanding how to address it. Among the strongest predictors of turnover risk is low participation in employee engagement surveys.
Additionally, low scores on questions that measure whether respondents feel a sense of belonging is a key indicator of disengagement among nurses. Improving a sense of belonging is a strong and effective retention strategy for health systems.
Redirecting these trends requires health systems to be proactive in understanding how their workforce feels about the organization’s ability to support them throughout the pandemic and beyond, according to Press Ganey.
The analysis recommends:
Measure often the pulse of your team. Knowing how your team members feel is instrumental in deciding on the appropriate next steps.
Once results have been collected through ongoing pulse surveys and an action plan has been established to address concerns, monitor any movement in the data. This allows challenges and opportunities to be noted and improved upon continuously.
Good, clear communication is key. Know which communication channels your team members are engaged with, and use those channels to share information as transparently and often as you can. Acknowledge what information was gathered through pulse surveys and document the actions taken to respond to employee feedback.
Ensure that each team member feels appreciated for the lifesaving care they help provide daily.
"Nurses who are on the fence about leaving the profession altogether are watching to see if leaders are really listening and willing to tackle tough issues," Doucette said, "or just going through the motions."
The ETS, which includes requirements on personal protective equipment (PPE), patient and visitor screening, and employee notification within 24 hours of the employer becoming aware of exposure, is the first-of-its-kind enforceable federal COVID-19 standard that went into effect July 21.
However, nurses still face problems with access to testing, being notified in a timely manner when they are exposed, inadequate respiratory protection, unsafe staffing, mental health, and workplace violence, the survey reveals.
Compared to results from the last survey in March 2021, RNs also reported inadequate COVID screening and testing rates for patients who enter or are admitted to a healthcare facility and a decrease in dedicated COVID units.
"We are more than 18 months into the pandemic, yet hospitals are still not doing enough to ensure the safety of nurses, patients, and other healthcare workers,” NNU executive director Bonnie Castillo, RN, said.
"COVID cases are surging to their highest levels yet in some areas of the country, and some ICUs are over capacity," Castillo said. "Nurses need optimal personal protective equipment. Healthcare employers must notify nurses as soon as possible when they are exposed and make it easier for RNs and other healthcare workers to get tested."
Highlights from the survey include:
More than 75% of hospital nurses are not timely notified of COVID exposure. About 23% of hospital RNs reported timely notification of exposure by their employers, down from 31.6 percent reported in March 2021.
Access to testing is an issue at some hospitals. About 41% of RNs at hospitals reported that any staff who asks for testing has access; nearly 20% said access to testing is limited at their facility; and 7% said testing is not available where they work. Of nurses who answered additional questions on employer testing, 58% said only staff who are symptomatic can get tested, "a troubling statistic as scientific research has found that about half of all COVID transmissions are from asymptomatic and pre-symptomatic individuals who were infected," NNU said.
Not all patients and visitors are screened for COVID. Two-thirds of hospital RNs report that all patients are screened for COVID-19 symptoms before or upon arrival at the facility. Regarding visitors, 53% of the RNs reported that every visitor is screened for COVID-19 and symptoms before or upon arrival.
Hospital nurses are still not provided optimal PPE when caring for COVID-positive patients or those suspected of having COVID. Nearly 61% percent of hospital RNs reported wearing a respirator for every COVID-positive patient encounter, down from nearly 75% in the March 2021 survey. About 40% reported that respirators are worn when caring for patients suspected of having COVID or whose tests results are not completed while about 62% reported using surgical masks for those patients.
COVID-19 continues to have a deep impact on the mental health of hospital nurses. Nearly 42% fear they will contract Covid; 53.5% feel stressed more often than before the pandemic; and more than one-third feel traumatized by their experiences caring for patients.