Causes and Impacts of the Healthcare Workforce Crisis
Chartis: Let’s start by looking at some of the issues at the roots of this workforce crisis.
Christian Dankers, MD:
A fundamental problem in healthcare right now is that we’re seeing increased volume and complexity of patients, and patients and stakeholders have understandably increased expectations about healthcare quality. But we’ve not adapted the way we provide care. We’re still using fundamentally old, traditional models of providing care.
Many organizations have accommodated these increased complexities and increased demands by asking more of the individual providers and staff. Much of what we’re seeing in burnout is a result of employees increasingly being asked to take on more or to do more with less—which makes it hard to provide the kind of care that they want to provide.
It’s not terribly surprising that people are stressed and strained as a result, and then you throw COVID on top of that, and it’s very clear that our normal ways of doing things are not sustainable.
Terri Carbone, RN:
Even before the pandemic, we had knowledge that there was an approaching shortage of physicians and that things were going to look bad in the future. People were beginning to make plans around that to beef up the workforce. But this happened so quickly, with COVID accelerating the problem and the shortages. That has really compounded the issue.
Elizabeth Conrad:
I agree with Christian and Terri. One of the things we have to remember is that pre-pandemic, we already had a very stressed workforce. We are trying to do the impossible, and in many cases, with insufficient levels of reimbursement. That, coupled with our old-school ways of thinking and doing things, has really gotten in the way of being able to provide people with the support that they need, particularly those closest to the patient. That’s where we see it most—the closer you are to the patient, the more stress and the bigger the issues are with engagement.
Chartis: As people have left the healthcare workforce in droves, what has this meant for provider organizations, for patients, and for the employees themselves?
Dankers:
It’s been devastating.
For those who remain, the job is to pick up the slack. I was on clinical service a couple weeks ago, and there were not enough staff to fill the provider slots that we usually have. So we just did it ourselves. It was tough. There are other front-line staff who have it much worse, but for me it was an experience that made the broader problem very real. Patients need care, and if we don’t have the staff, we have to make do. And when the care model does not adapt to a changing environment, it does not set us up well to provide outstanding care.
That has not only had a tremendous impact on the staff who remain but also has an impact on the patients. During COVID, when this crisis has been at its worst, we’ve seen patient safety and quality decline. People are working hard on how to get that back on track, but it’s very difficult when situations are created when it feels like it’s not possible to do a good job. That clearly impacts the organization, the patients, and the staff that remain.
Elizabeth has talked about this—there’s a real moral injury that comes from trying to provide care that you don’t feel good about. That’s another major impact on staff who remain.
Chartis: There are a lot of compounding factors from these experiences in the workforce. How have these experiences impacted healthcare workers who have stayed in the field?
Duane Reynolds:
Many of the individuals who are left feel disengaged. They feel burnt out by the work that they’re having to do. It’s taking both a mental and physical toll on them. As a result, I think that they have a lot of dissatisfaction, but likely also a feeling of a need to continue the work because of their commitment to patients, which is certainly admirable. However, without some type of reprieve, I think we’re going to continue to erode our workforce.
It’s important that we lean into well-being, and lean into creating a space where employees can feel valued and taken care of. A place where they are getting as much out of the organization as we’re asking of them.
Kim Fox:
We have to realize as well that workforce challenges are not only in healthcare. Everyone is taking stock of what’s important to them in their personal lives, of how work is part of their lives, and what that balance is.
With the idea of connectedness to the work and a sense of purpose and mission, we need to think about how we’re reconnecting our healthcare workforce to that mission and why they’re there. We need to have conversations around that, listen to what they have to say, and talk about it. Because reconnecting brings that joy to the surface again that we all need at this time.
Conrad:
Kim, I’m really glad that you mentioned reconnecting staff to mission because that’s really what brings so many people to healthcare. For sure what has kept them in our world is that sense that they really do have an opportunity to make a difference, to really impact the lives of others in ways that they can see.
This experience has been demoralizing and difficult for so many people. We are looking at whole people. Historically the thinking has been, “Leave everything that’s going on at the door.” But the fact of the matter is that we have whole people with families, with spouses perhaps who lost their job, who had significant impacts, including no one to watch the kids while they came to work. With the level of stress and anxiety that’s already in the community, coupled with the increase in violence, we need to recognize and support the whole person.
Sally Pelletier:
I also want to recognize that recent changes aren’t all negative. For medical staff services, for instance, the field accelerated to where it actually should have been before—they’ve learned to work smarter and embrace automation. The function of credentialing and supporting the medical staff is now almost totally automated, and most, if not all, organizations are now paperless. That has made organizations realize that these functions can be performed in a remote environment, which lends itself to a better work-life balance for many folks.
With the physician shortage and the need to onboard and credential new practitioners so they can start delivering patient care immediately, medical staff services and credentialing staff are now highly valued for their contribution to putting that clinician in front of a patient that much quicker. Highly effective organizations recognize the value and are expressing that to the folks who perform these functions, which contributes to the sense of belonging employees need.
What's Needed to Create an Environment for the Healthcare Workforce to Thrive
Chartis: As we captured in our recent survey of healthcare executives, organizations have been trying a lot of Band-Aid solutions. But what are the core components of a long-term strategy that fosters well-being and belonging and enables the workforce to thrive?
Dankers:
It comes down to this: what is the experience of doing the job? We help a lot of hospitals that want to become high reliability organizations. One of the core tenets of this work is understanding the challenges, the pressures, and the situation at the front line.
As a strategy, many organizations have tried to manage really difficult front-line conditions by building resilience in employees. But you can’t yoga or spin class your way out of a terrible work environment. That’s not a long-term, sustainable strategy. At some level, you have to figure out how to understand that front-line perspective, help and engage front-line workers in designing systems that accomplish your key goals, and do so in a way that is realistic.
That’s hard because it involves trade-offs in a situation where we are forced to choose because we don’t have the workforce or the ability to do everything that we want to do. Again, not easy, but that is the work. That is going to be an important part of finding our way out of this crisis—to understand and reimagine many of these processes and workflows by understanding and engaging the front line.
Fox:
All of our clients have aggressive recruitment goals—the numbers of nurses they need to bring in is often in the hundreds, sometimes thousands, of recruits. Let’s be honest that the only way to do that is “stealing” from others. There are only so many brand-new nurses. In order to do that, we’re unfortunately having to take from somewhere else.
How much different can the job be? What can be different is the place you’re doing your work. What does it feel like? What is the culture? How does my leadership feel about me? Do they ever ask me about my job? Do they ask me to help create the environment I want to work in?
At some point, the differentiation has to be there—and that differentiation has to be based on what the organization feels like to work within. We need to think about that in addition to making it more efficient and all those sorts of improvements. But if it feels the same as every other place, will I go somewhere else for a dollar more? We have to think about what the culture is we’re creating.
Dankers:
That’s such a great point, Kim. It is such an important component, and redesigning the work and engaging the front line is going to take some time. That is not easy work. But if you feel as a front-line worker that you are connected to the mission, you’re engaged in the solution, you’re working with and for people you believe in, that goes a long way not only in helping to get that engagement and moving toward those better work environments but also in making it more tolerable along that journey.
Carbone:
I think you’ve hit the nail on the head. People lost so much control during the pandemic over so many different things. They need to regain that structure with some control over their environment. Bring to the forefront the shared decision-making and leverage the expertise of those folks at the front line who did stick it out and did come up with new ways to do things. Debrief about what you learned and how you can apply that going forward. Allowing workers to have that control over their environment to some degree is really going to help them to feel much more engaged.
Reynolds:
We have developed a framework for creating this new normal, which identifies 6 key components:
1. Offering meaningful and differentiated benefits.
Benefits can go beyond the traditional ones. For instance, think about how your organization can support caregivers who may be taking care of family members or children at home.
2. Fostering a culture of belonging and engagement.
Your organization can make sure that people feel psychologically safe, that they are part of the environment, and can bring their full selves to work.
3. Championing career advancement and training opportunities.
For instance, your organization could establish new and innovative programs that lead employees who so desire along a forward-looking career trajectory.
4. Providing competitive and equitable compensation.
The equity piece is key. Particularly with front-line workers in healthcare, organizations need to make sure that they’re taking care of individuals from a competitive wage standpoint, making sure that everybody is at a living wage and is receiving equity in that process.
5. Coalescing around a common mission and purpose.
This should be at the center of what organizations are trying to do. People in healthcare came here for a reason. Organizations have to help the individuals in their workforce think about and reconnect with that purpose because it is what will continue to drive them to be a part of this wonderful industry. Part of that has to do with health equity and well-being. Health equity is about us all. We are all patients. Employees are patients, so their ability to connect with that deeper purpose of well-being and belonging is so intrinsic to the work.
6. Supporting the achievement of work- and home-life goals.
Think about remote work, for instance. Make sure that your organization is being flexible with people in terms of the work that they do, how they do their work, and providing support programs for mental health and physical health. Work toward creating the most frictionless workflows possible that will help to decrease the administrative burden and clinical burden that our workforce is facing.
Those are 6 things that we think are important, and it coalesces with everything that each one of us contributed here.
Dankers:
I want to pick up on one aspect that resonated with me, and that’s psychological safety. Creating an environment where employees feel comfortable speaking up about staff safety, patient safety, or any other concerns without fear of a punitive response is so key to engagement, connection to the mission, and feeling that safety culture. Many organizations are familiar with the term “just culture,” but there are things that leadership and others can do to foster and create that environment, and that is such an important component of staff engagement.
Reynolds:
We’ve thought about it a lot from the perspective of patient safety and understanding. A just culture must exist in order to achieve quality outcomes, and we have to apply that same concept to our employees. Create a space where they feel valued, can challenge the status quo, can contribute their thoughts and opinions without fear of retaliation and reprimand. We have an opportunity to give people a voice and ensure that they’re a part of solving decisions and challenging the organization to do better because they truly do care about its success.
Conrad:
Those items certainly are consistent with the research. It doesn’t take very long to see that the common themes are true.
I am very optimistic about the future of our workforce. If we step back and we do give people a voice, reconnect to mission, and focus on creating both physical and psychological safety, it goes right back to quality, the patient experience, and the employee experience.
As you pointed out, our employees live in our communities. They are our patients and our friends. They are members of our family. These are the things that many of us grew up with when we first went into healthcare 30, or 40, or 50 years ago. I don’t think it’s that we don’t know the answer; I think that we have to recommit ourselves as organizations, as leaders, to looking at every single piece of work that we’re asking our employees to do: Is it necessary? Is it meaningful? Can it be done by potentially somebody else if that higher-licensed person can’t do it?
We also have to think about how we’re going to grow this workforce. We can’t continue to compete with each other. We’re all in the same business, which is taking care of our communities. It’s a self-limiting strategy to continue to do that as opposed to saying, as a community of healthcare providers, what do we want to ensure, regardless of where you work, that your experience is going to be a positive experience. What do we need to do to grow the base of employees potentially who can provide the kind of care that we want to provide?
Pelletier:
It will be important to remove things that are non-value-added and that can erode the mission for the workforce that comes in. Most of us who are in healthcare, whether we’re on the front line or not, came in because we want to do the right thing for the patient. And that’s what drives us to get up and come to work in the morning. What I’ve seen is a frustration with the busywork or the culture of the “we’ve always done it this way” mentality that really drives those non-value-added activities.
So organizations have to take a look at things that don’t add value to the process and make their workers frustrated. In some cases, that means looking at your infrastructure or those documents that drive the process. Are those processes supporting the quality and contributing to a highly reliable organization, or are they simply waste and need to be discarded?
Immediate Steps Healthcare Organizations Can Take Now
Chartis: As organizations work toward long-term, transformative changes, what are some immediate steps that organizations can take now to start themselves down that path?
Carbone:
Tactically, we have to have the mindset of doing more with less while asking how we make ourselves more efficient, more flexible, and agile. How can we cover more in a way that is easier for folks? You want to make the right things to do the easy things to do. How do we use the technology that we have optimally? How do we ensure that we have standards across all of the organizations we’re going to expect people to flex to, to move between our hospitals, to be more agile?
We need to make sure that when I go from one hospital to the other, I’m going to encounter the same type of environment, the same technology. It takes away some of the stress and strain of moving from one place to the other.
Pelletier:
The Great Resignation as well as the pandemic have served as a catalyst for health systems to begin to break down those silos, break down the barriers and the divisions toward the goal of being more flexible to meet patient needs. Part of that does mean being more flexible with staff—the agility to be able to move physicians and other practitioners from one hospital to another to be able to meet those demands.
There are several elements that organizations can address to make them nimbler and allow those practitioners to go from one place to the other: System-wide documents to move towards include bylaws, credentialing policies and procedures, privileging, a peer review, and integrating credentialing functions. You have to migrate away from silos and have a centralized function that’s supporting every entity within that healthcare system. Also, of course, you have to make sure that there’s a single source of truth with all the information related to the physicians and practitioners that can then populate or feed those other downstream business applications.
Dankers:
What can organizations do? One of the ways to start on that journey is to engage the people who know the work the best, which are those front-line workers. No one is under any illusion that this is going to be fast or easy, but that engagement and connection will start to not only get you closer to a more efficient and better practice but also will result in better engagement and satisfaction. That is something that leadership can own and promote. There are organizational structures that healthcare organizations can put into place to accomplish this. That is part of the journey to high reliability.
Going along with that is psychological safety. Really committing and asking yourself as a leader, “Do my employees feel psychologically and physically safe?” Then making sure that if you have any question about it, that it is something that needs to be an explicit leadership-driven initiative. You won’t get far if staff are frightened about bringing up concerns both about their own safety or that of the patients.
Fox:
Harness the power of simple questions like, “What do you think?” “How have you seen that work elsewhere?” “How are you feeling today?” The power of simple questions and listening for the answers cannot be overstated. We can use the power of that as leaders.
Carbone:
After a big hiring event with a former employer, we brought in a lot of new people to go through orientation. And once they got there, they spent a few months learning the space, but they never really felt connected. They really didn’t feel that it was the spot for them. That’s OK if you really don’t feel that this is the place for you to be. But how do we make them feel more welcomed and engaged early on? How do we ensure that leadership is meeting with these folks, understanding their experience?
Maybe your orientation program needs a little work. Maybe there are some things that aren’t value-added to the people who are coming in. How can you listen to them, understand what’s working well and what’s not working well, and pivot? Try new things. Don’t be afraid to fail—fail early and often. Don’t make the same mistakes twice. Keep things going, but listen to your folks. Make them feel engaged early on so that you can ensure that they have a long tenure with your organization.
Conrad:
We still take too long to get people through our recruitment process. It’s incredibly important that we do the essentials, like background checks, because we never want to bring a dangerous person into a patient care environment. But there are so many steps and process delays that we see in recruitment. There are good reasons for all of it, but the gold standard now is 24-hour turnaround for an offer. It’s really important to be able to move a lot faster, attaching people properly to the organization when they’re there.
It’s not helpful when somebody comes to work and their boss doesn’t take the time to have lunch with them their first day. Or to ask them at the end of the first week how things are going, or what can I do to get you more information. So we end up dropping people into situations, and they immediately are swimming and gasping for air, and not providing them with the basic courtesies around welcoming them to a new culture.
I also think there’s a real opportunity now for us to re-recruit our alumni with great consideration and care for the folks who stuck it through. We have to be sure we don’t disrespect them while we go back to some of the folks who left and say, “You know what, everybody made the decisions they needed to make during the pandemic. We want to be sure that we have an open-door policy. We want to extend an invitation for you to come and talk with us again about how this may still be an important part of your life.”
We also have to be prepared to create and offer the kinds of support that are necessary for people to get through pandemic recovery. The culture of wellness must run deep. We have to do a better job of taking care of people who have given such a big part of themselves to us. For many of our staff, they’ve left because we were asking too much. We need to figure out a way to destigmatize that process of returning back to work. Those are some immediate strategies that I see organizations using to great effect.
Dankers:
We have a tremendous opportunity in healthcare right now. We’re still dealing with people who, at their core, want to take good care of patients, to be good at their jobs, and to provide value in whatever form that takes for them. We are in the situation where it has become an inescapable conclusion that we need to be doing things differently because it’s not sustainable.
A healthcare leader I used to work with said, “Never waste a crisis.” I think that’s where we are now. This has been a wake-up call. Something needed to change, and now we have a real opportunity to support organizations, to work with organizations to really change the way they do things for the better. I’m optimistic that we will come out of this on the other side stronger, better, and more able to care for our patients and employees.
Chartis: Thank you for sharing your perspectives and insights about how the industry can move forward—not only addressing these pressing problems in the moment but looking at this as a situation that’s an opportunity to create a transformed environment that allows organizations, patients, and employees to thrive.
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