March 31, 2021

Episode 51: How COVID-19 has impacted the nursing workforce

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Description

Our guest for this episode is Dr. Joanne Spetz, a professor of Health Policy Studies, Family and Community Medicine, and Nursing at UCSF. She’s also a researcher who focuses on the economics of the healthcare workforce, and her insights into the nursing workforce are more relevant than ever in the midst of a pandemic that has stretched our supply of nurses to the breaking point. 

In this conversation, Joanne talks with Dr. Nurse Dan about the trends she’s seeing across the profession, including a disturbing acceleration of retirements and nurses leaving the workforce. She previews insights from the bi-annual study she does in partnership with the California Board of Nursing, which looked at the impact of the COVID-19 pandemic on the state’s nurses this year. Joanne also shares her thoughts on how we can better use data to inform everything from healthcare policy to education to hiring and training.

Links to recommended reading: 

Podcast

Transcript

Dan:
Joanne, welcome to the show.

Joanne:
Thanks for having me.

Dan:
All right. So tell us what you're working on right now. I mean, you are like the workforce guru. I know we've talked a lot about nursing workforce in California and the data behind it, but we'd love to know what you're focused on at the moment.

Joanne:
I think the project that your listeners would be most interested in is some survey work we've been doing for the California Board of Registered Nursing. We've been doing surveys for the board since 2006. It's every two years, there's a survey of registered nurses. And then there are annual surveys of nursing schools. This year survey went out into the field a couple months late. It should have gone out in April, but there was this pandemic that slowed everything down a bit. And so it went out into the field in late July. And we are analyzing the first 2,000 responses that came in via the online response option. It's been pretty impressive to look at those data. And honestly, really kind of sobering to see that. And those data were from before the most recent winter surges of the pandemic. So a level of stress that we're seeing in those first few months of the pandemic, I can only imagine when we get the next batch of data, what it's going to look like.

Dan:
What are some of the early insights that you're seeing there? What are some trends that might be interesting?

Joanne:
There are a few things that are showing up in the data. Think about it from the two ends of the experience spectrum. For nurses who are relatively new to the profession and relatively newly licensed, there've been some written in comments that are a mix of, "Oh my gosh, trial by fire." And just the challenge of walking into a new clinical job with the amount of stress and chaos that the pandemic's created. And then actually also, a lot of new graduates being concerned that they can't find jobs, which isn't surprising.

Joanne:
I think a lot of hospitals and other employers have been in a position where they have not really felt financially able or organizationally able to hire. There've been a few comments written in the open-ended comments about just whatever mentoring and onboarding program might've existed doesn't really exist anymore for a lot of hospitals. Just again, because of the chaos and the circumstances.

Joanne:
On the kind of the other end of the experience spectrum, the employment rates of nurses ages 60 and up dropped significantly compared to two years prior. And there are a lot of open-ended comments around, "My elderly mother lives with us, and I've asked for a non-patient care assignment because I don't want to expose my family." To people just saying, "I'm too old for this stress. I'm out." And so all of those retirements that we've been trying to prepare for, for the baby boom, it looks like some chunk of those is happening a lot more precipitously than we expected, so that's a little unnerving.

Dan:
Those are all that we've heard as well. And it's good that the data kind of confirm it. And it's interesting. I mean, on one end, health systems kind of clamped down, stopped hiring, but on the other end they also needed help. And so, they had tons of travel nurses and had lots of open roles. I mean, at one point we had three times the number of roles open on our platform than we've ever had. And then at the same time, we're hearing new grads can't get jobs or we can't bring them on in any capacity, whether it's patient care or even to like take the role of someone else who can move over and do patient care or something. It's just really interesting how systems were thinking about the workforce. And then, to couple that with the rumors that I've heard from colleagues of the retirements, the mass retirements that potentially will come from this as well.

Dan:
And I think that just puts us in a really interesting spot for healthcare workforce. So like, are we in a shortage now, Joanne? Is this going to happen for real now? I mean, we always say we're in a shortage, but is it worse?

Joanne:
Whenever somebody says, I think we have a nursing shortage, I think the answer we should all provide to that is what do you mean by shortage? And where is it happening? It's really almost the beginning of the question, not the answer. You know, generally what we've been hearing from employers over the past five or six years is a lot of concern about retirements of experienced nurses. The nurses who've been in the ICU for 10 years or 20 years, the peri-operative nurses, labor and delivery, emergency department, and the NICU and ICU in general. Those are the areas where we hear the most complaints and concerns. But at the same time employers in these surveys we've done of employers will say, "Oh, but there are too many new grads. There's a glut of new grads in our area." And I think this speaks to what you're talking about.

Joanne:
There really is not a great system right now for hospitals to feel like they have the resources to do the extra hiring they need to do to skill up people, so they're ready to take on those roles that the experienced nurses are going to vacate. Just as the pandemic has highlighted all the social inequities and all of our health system failings, I think it's also revealing this failing or this gap in really anticipating and thinking proactively about impending retirement and being really thoughtful about how to prepare for those. And there are a lot of strategies that they could be using. I've heard of some organizations actually leveraging the traveling nurse workforce as a mechanism to help onboard new graduates. But those kinds of strategies, while in the middle of a pandemic, you can't really expect anybody to be too strategic.

Dan:
Right, yeah.

Joanne:
This really has highlighted and brought to the surface issues that have been festering for a while already.

Dan:
That brings up a couple of points that I'm interested in. One is like we've heard the shortage since, I don't know, I feel like the 70s. There's literature that goes back forever on the nursing shortage. And in my head, I hear the same conversations of we have this surplus of new grads. We don't have enough specialists. And I wondered like, is it the workforce data that's flawed? Like we don't actually know how many nurses and what they can do and where they are and how willing they are to work, or is there really a number shortage? I'm curious what your thought is there.

Joanne:
There is a lot of data. Fortunately, nursing is a profession where there's a good amount of data. So we can't claim that we don't know. It is very hard to project demand. I will give that because there is a lot of opportunity to shift the way that you deliver care a little bit. Most states don't have minimum staffing ratios in hospitals. So there's a little more room for them to shift their workforce around or change their staffing ratios in order to address short-term kind of imbalances. I mean, the broader dynamic that you see again is related to this long-term planning. And I'll use the 1990s as an example, right? During the 1990s, managed care really exploded in the United States. And that led to big reductions in people getting hospitalized, big reductions in length of stay. Sicker and quicker was the term that people still use to some degree to talk about that pattern of care.

Joanne:
So with fewer people in the hospital, then hospitals were laying off nurses because they didn't need as many nurses. So you started seeing reports in the early to mid 1990s that were saying, oh, nursing is going to change completely. Patients won't be in hospitals anymore. Therefore, we should be closing nursing schools. And literally, nursing schools closed. And those of us who watched these kinds of cycles since the 1970s said-

Dan:
"No, don't do that."

Joanne:
I know. I was a small child in the 70s, so I didn't actually observe it. But if you look at the literature going back that far, it's like, don't do this. You're about to set up another shortage cycle, because managed care only tamp things down so much. And then we returned back to that steep slope of increase of hospitalizations again. Population is getting older. Population has more chronic conditions.

Joanne:
Of course, you get more hospitalization. So once that first adjustment happened, we went right back onto that growth trajectory, but we'd closed nursing schools. So that was the origins of really the shortage that lasted from around like what? 1998 or '99 up through the financial crisis of 2008. That worries me a little bit right now. You kind of have this combination of we have a shortage. Now, we have a surplus. What's going on? A lot of the shortage data suggest it is really certain geographies. It's not everywhere and not all the time. And it's also certain specialties or areas of expertise. There is that need to help get nurses to move to where the jobs and needs are, either on a traveling basis or on a permanent. Or for many people, they do a traveler cycle and then they decide where they want to move permanently. And also, as I said, to figure out how do you rapidly get a new graduate, skilled up to move into a specialty area, because that is where people are retiring from.

Dan:
Yeah, I've been doing some work with ACN around kind of innovating and kind of pushed the walls of the nursing schools. And that's one of the proposals that I pitched in the last presentation I did at one of their conferences was maybe the generalist graduate isn't relevant anymore. And while we need kind of that med surge talent that's still there, med surge is almost like an ICU 10 years ago. And so, maybe we need to actually specialize similar to what medicine does and the residency program is specialized earlier and maybe not create generalists anymore. And you graduate nursing school as a NICU nurse potentially. Or at least in pediatrics in some way, so that you have a more specialized foundation to jump into some of these specialties where there just aren't enough people.

Joanne:
Oh, exactly. And you know, the bachelor's degree programs are in a great position to do that because they do have more space and time for electives. And there may be also opportunities to expose or encourage nursing students to think that some fields that we don't often view as viable and important entry points are entry points. I mean, long-term care and nursing homes really need good nursing talent. And within the hiring world, they are often viewed as kind of the ugly stepchild of a new hire or kind of a new graduate's first job. But for some people who do land in their first job in a nursing home, they realize that they love geriatric nursing care and wouldn't trade it for anything. And maybe they shift into home health or they shift into other geriatric environments. But you know, if you're interested in school nursing, let's think about how to accelerate you to school nursing or accelerate you to labor and delivery. And the electives in the undergraduate education is an opportunity to do that.

Dan:
I love that. And I'm seeing at least in many schools, the shift to have an entry point into ambulatory care more generally, which I think is great as care continues to kind of move out of the hospital, or routine care at least moves out of the hospital. And so I think that's a great first step, but I think, yeah, I mean, long-term care is definitely not talked about a lot, other than your first rotation nursing school. And it's definitely not made to be like the glamorous life of an ER/L&D nurse, which I feel like 90% of nurses raise their hand and want to be that when they're in nursing school. So I think we can do a better job of just bringing light to what those different areas of need are and how you can contribute as a nurse.

Joanne:
Yeah, absolutely. And I mean, that is one of the beautiful things about nursing as a profession is there are so many different areas that a person can specialize in. And even if a person starts specializing in one area early in their career, there's a lot of opportunity to pivot and learn new things as you go through career.

Dan:
Now, does that show up in the data? Do those pivots come out in any way? And are there any trends that you see there?

Joanne:
That's a great question. The data that we have does not do a great job of tracing people's career pathways for a long time. So you can look at kind of year to year changes, but you don't get a lot of information about the overall life course of a nurse. We do see for nurses, as I think anecdotally, everybody thinks is happening. The data really show that early on new graduate nurses tend to land in hospitals, and then they tend to change jobs relatively frequently, early in their careers. They then will kind of stick in a place for a while. And then you see people kind of gradually move out into home health or nursing informatics or management, or kind of ambulatory care or shift out into other roles. I think if we had newer data, I bet we would see more new graduates starting in ambulatory care or starting in longterm care than we used to.

Dan:
Yeah, that'd be interesting. It would be kind of cool to figure out if we could trace a large population of nurses in their career paths. I feel like there is so much opportunity. And a lot of what I hear is anecdotal, but it'd be cool to kind of figure out what the average nurse does, how many times they change roles, specialties, whatever. It'd be kind of fun.

Joanne:
Yes, the best we could do with that was years ago for a project in California, we collaborated with the Employment Development Department, which collects all the payroll tax data. And we got the Community College Chancellor's Office to dump over to the Employment Development Department the information about people who graduated from nursing programs for two different cohorts. And then, EDD was able to find them in the payroll data and then gave to us tables that said, of the however many nurses that you gave us the info for, five years later, we found 85% of them working in California. And then they were able to kind of trace what industries they were in and how they played out over time. Obviously, they weren't going to give us anybody's names or social security numbers. So we couldn't really go into too much depth, but it was, I think, one of the first times that there had been a nice systematic effort to begin to look at what that life cycle is.

Dan:
That's interesting. It'd be fun to kind of do that again and see how the workforce is changing over time, especially with the millennial workforce and newer nurses entering the profession and kind of wanting that flexibility. And we're seeing a huge uptick in the travel interest of travel nursing. And anyway, I think there's a lot of cool trends there. I'm curious from the data, you mentioned the board of nursing, what did they do with these reports? How do they act on it? Do they create policy? Do they change process? Like what are their actions from the data that they get?

Joanne:
The old reports that we did that were during that terrible nursing shortage really laid the groundwork for not as much activity from the board, but actually from the legislature and from foundations to help grow our nursing education. So over about a 10 year period, our nursing programs in California more than doubled in their capacity. That was early on what we projected needed to happen in order to fulfill the gap that was created by the impending retirement of baby boomers.

Joanne:
Now, I know part of the board's process of approving new nursing schools and expansions of nursing schools, they're supposed to take into account kind of the capacity of education in the area and keep an eye on whether an expansion or creation of a school is going to potentially bump other nursing schools out of the clinical rotations they already have. And my data don't really speak to that tremendously well, although the survey we do of nursing schools does include some questions about whether there have been changes in clinical rotations and the reasons for that.

Joanne:
So those data help them keep track of that. What hasn't happened in the past, but will happen I think for the survey that we'll do in 2022, is regional forecasts of supply and demand. We've been doing those at the state level, but we have done regional forecast only intermittently because that hasn't been part of the board's funding. And it has been a little bit more catches catch can and finding time and resources to do the regional forecast.

Joanne:
But the board has indicated that they'd like us to bring that into the next contract cycle with them, which is great because California is so big. I mean, if you took California and flipped it over and laid it on top of the East coast, it's essentially New Jersey to South Carolina. So what's happening in San Francisco does not necessarily tell you a lot about what's happening in Bakersfield.

Dan:
Yeah. And we saw that with the pandemic too, right? It was like just different worlds. Every part of California had a different impact did. It had a different surge. It had a different response. And yeah, you can't lump California into one bucket I don't think very well. I think there was a proposal at one point to break it up into like five different states or something I saw that during the last election cycle. It'd be interesting to see. And the California Board of Nursing has had challenges too. I mean, we worked across all boards of nursing and some boards responded to the pandemic really quickly.

Dan:
And others, initially like California is still had 13 weeks to get your license. So to actually move the supply of nurses into the state quickly without the emergency authorization was hard. And I just wondered if we have better data, better insight to that supply and demand, if they would change process like that, or be able to flip quicker than they could. Other states were able to kind of flip and to be able to license nurses within a day, 24 hours. Like Washington did that and California had to turn it over to the Office of Emergency Services. I just wonder if with better data, can we improve the process at the board level too?

Joanne:
Yeah. I mean, I think that that is what the board leadership really in general hopes to achieve. I don't underestimate the challenge. I think there's more than half a million California nurse licenses out there. So just the basic processing for renewals is extraordinary, right? No state has anywhere near that number of nurses. And so, it's a huge volume of work that they do. And over the decades in the past, there have been issues with prior governors. Not the current one. And I don't believe it was an issue with Governor Brown, but governors in decades past, like borrowing money from the board's revenues. So the board didn't have the money to hire people to process licenses or kind of oversight work that they're supposed to do.

Joanne:
It's a very challenging job. The new executive director there, Loretta Melby, she has got a lot of work on her hands. And in addition to that, they're also working on the new advanced practice regulations because California passed a bill to expand the scope of practice for nurse practitioners and the board needs to propagate all the regulations around that, which is another big giant lift for them.

Dan:
Yeah. I'm so happy that is moving forward too. We need it and California, I think, we'll benefit from APRN's advancing their practice. So that's awesome. That kind of brings me into the policy piece. So what can nurses, frontline nurses, nurse leaders do to help bring light to workforce issues and policies related to improving the nursing profession, but ultimately just getting care to the public?

Joanne:
Oh boy, there are a lot of venues. Nurses, as often gets reported, really are the most trusted profession. And as such, that means that they have a voice that people listen to, which can't be said for every single profession out there in this country. There are other professions that also need to be listened to, but get ignored. And nurses really do have a nice position because of the amount of respect that they have.

Joanne:
And I think that that kind of policy engagement can come anywhere from getting involved in your own hospital's policies, through getting involved in your community policies. It's really exciting when we see nurses getting involved in their cities, parks, and recreation department, or getting interested in the school board because those are all areas that really affect population health and having a nursing voice in those areas is really important.

Joanne:
So I think there's a whole range of things and thinking about the workplace environment, I've seen nurses do everything from getting involved in whatever their kind of leadership organization chapters are in California. It's the Association of California Nurse Leaders. Nurses in some areas, they have union representation and that can provide an opportunity for voice and leadership development. You've got all kinds of different specialty associations and professional groups to get involved in. And a lot of hospitals have staff leadership joint committees that are opportunities to have a voice in there.

Joanne:
And getting to know who your local representatives is, is important because you're a nurse. That brings you a credibility that a lot of the public envies and gives you an opportunity perhaps to have a window or a door into talking with your local state representative or other city council members or other local leaders.

Dan:
So Joanne, I'm interested in your thoughts on the future of innovation. So if you could have your way with workforce data innovation, what would that future look like? Like what data would you have? What decisions could we do better? Like what's that future state that would be ideal for you?

Joanne:
Boy, I would love to come up with a way to develop a data system so that all the employers, not just hospitals, but I mean, hospitals are 60 or 65% of nursing employment. But really all the employers of nurses had a mechanism by which they could do a great job of projecting what retirements and turnover they might expect in the next two or three years. And some very well-defined pipelines or recommendations about what that means for the hiring they should be doing today and training around that hiring.

Joanne:
I think some hospitals have those kinds of systems, but it always amazes me how many hospitals get surprised when they have three operating room nurse retire this year, even though if they had gone back and looked at their data, they would have seen like, oh, wait, three of our OR nurses are ages 62 and 63. What are the odds that they're going to retire within the next couple of years? But at the same time, I appreciate that not all HR systems are really well-designed to compile the data in the kinds of ways that you would want to do those drill downs. And that is something that nurse executives really need to have available to them without having to ask HR for all these custom reports and all of these heroics essentially.

Dan:
Yeah. All the manual data pulls on how many nurses have a bachelor's degree in things. I feel like I've been in organizations where that's the norm too.

Joanne:
Yeah. I mean, you really do need to have the resources for that strategic workforce planning. And as a data nerd who then wants to look at things at more the 30,000 foot level, if there was a way to kind of compile that information, so then from a statewide perspective, we could say, huh, what the HR systems and the hospitals are telling us is consistent or different from what we're getting from these other surveys that we do. And that can help us then say, we really need to expand nursing education programs by X, Y, Z, try to push those recommendations forward.

Joanne:
Of course, funding is always an issue. There's always a need for better availability for scholarships, for nursing students. The Cal State and the community college systems are really a key entry point for people who want to go into nursing and don't want to have a lot of debt. But anytime there's a state budget crisis, those are the systems that take the brunt of it.

Dan:
Yeah. That's kind of my dream too. Is there a way to aggregate this data into the macro level so that we can actually better see the supply and demand of healthcare workforce and be proactive, but also better prepared for the next pandemic or emergency and move talent where it needs to be quickly. Joanne, this has been so great. And I'd love to hear, what would you like to hand off? What's that one nugget that you want to hand off to our audience about all your work and amazing insights?

Joanne:
I think the idea of nurse leaders and with support of all the staff in everybody who's working in nursing, trying to support the idea of better understanding nurses' talent, having that be in records. So that if there is a future emergency or a pandemic, it is really easy to see and identify people who had maybe ICU experience five years ago. It might not be in their HR record or their job title right now. But if you could quickly flag who those people were and say, "Hey, we need you." That would have been so valuable over the past year. And there are all kinds of emergencies.

Joanne:
I live in California. We have earthquakes and fires. And around the country, there are all kinds of different situations where being able to know what talent you have and rapidly deploy it to save people's lives is essential. I think that's an area where nurses can think about like, how can I put that out there that I have this history of experience and then how can nursing leaders leverage that information into a way that really helps them respond to the public's needs?

Dan:
Yeah, that sounds right in the wheelhouse of stuff we're working on. So that's exciting to hear that. Joanne, where can we find more information about you and your research and maybe connect with you if people have questions on what we talked about today?

Joanne:
A quick Google search of Joanne Spetz at UCSF hits me very quickly. And the UCSF emails are very easy to remember. It's just Joanne.Spetz@UCSF.edu.

Dan:
Cool. Joanne, thanks so much for being on the show. We'll put some of this stuff in the show notes, some of your publication links, and really get this out there. And thank you for bringing more light to your research and also to the healthcare workforce and what nurses can do about it.

Joanne:
My pleasure.

Thank you and welcome to the Trusted Community!
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