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SCCM Pod-512: The Link Between Workforce Retention and Patient Safety

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In the first of a series of podcast episodes focused on quality and patient safety, host Maureen A. Madden, DNP, RN, CPNC-AC, CCRN, FCCM, is joined by Anita J. Reddy, MD, MBA, FCCP, FCCM, and Jose Chavez, DNP, RN, ACCNS-AG, CCRN, FCCM. They discuss the links among patient safety, workforce retention, and how the COVID-19 pandemic shifted the landscape. They explore effective staff retention strategies that can impact patient care and enhance the resilience of healthcare organizations.

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Dr. Madden: Hello and welcome to the Society of Critical Care Medicine Podcast. I’m your host, Maureen Madden. Today we’re joined by Anita Reddy and Jose Chavez in the first episode of our multipart series discussing quality and patient safety in critical care. Dr. Reddy is a critical care physician at Cleveland Clinic and an associate professor at Case Western Reserve University in Cleveland, Ohio. Dr. Chavez is a DNP and a critical care clinical nurse specialist in the surgical intensive care unit at Cedars-Sinai in Los Angeles, California. Welcome to you both. Before we start, do you have any disclosures to report?

Dr. Chavez: Yes, I’m a consultant for Acura Medical, but I have no conflicts with this topic.

Dr. Madden: Dr. Reddy, any conflicts on your part, or disclosures?

Dr. Reddy: No, I have no conflicts or disclosures.

Dr. Madden: Thank you so much for that. This is something I think is really near and dear to all critical care clinicians―quality and safety. First of all, tell me, what’s your interest in quality and safety?

Dr. Reddy: I’ll go first. Thanks, Maureen, for hosting us on this podcast. Quality and patient safety is something that I’ve been very much interested in once and during my training. When I completed my training and came over to the Cleveland Clinic, I had the wonderful opportunity to serve as the quality officer at the Cleveland Clinic. That was a stepping-stone for me to be involved and actually lead the sepsis efforts at Cleveland Clinic. All of these committees really opened my eyes to the different ways that we can improve patient quality, patient safety, and actually patient experience as well.

Dr. Madden: Very good. Dr. Chavez?

Dr. Chavez: One of the reasons why I got involved in quality and safety is, as a CNS at Cedars-Sinai, I am part of the different policies and procedures and overseeing some of the safety in the ICU units. Being a part of SCCM and the Quality and Safety Committee, I felt I could get an oversight over just what other people are doing around the nation. Talking to people from different facilities from different states gave me some insight on what we can do here at my organization. That was one of the big things that led me to the committee.

But my involvement here is what started it all, my involvement with some policies and procedures and being on the review panels of RCAs or things about how we can improve, not just on a unit but an organizational level. I enjoy my time here on the Quality and Safety Committee and look forward to future things that we do.

Dr. Madden: I know I’m very grateful for all the work that both of you do at such large organizations as well as at SCCM so, first of all, thank you for doing that. But second is, talking about quality and safety, it’s become some of the buzzwords that have shown up in the past 10 to 15 years. For all of us engaged in critical care, we know the Institute of Medicine and a lot of their reports that came out are the drivers behind some of this.

Not that we didn’t always want safety and we didn’t want to provide quality care. It was a changing concept of really ensuring a nonpunitive environment and that things were being reported to an institution and to the organization so they could be looked at critically and see if there were areas that could be improved so we would have improved patient quality and improved safety.

Within that, as we’re talking about trying to retain multiprofessional clinicians in really such a high-stress environment, we know this is not ever intended to be punitive. But at the same time, sometimes there seems still to be that thought process associated with it. I’d love to hear your perspectives on it.

Dr. Reddy: I’ll comment on that first. I think after, or even during, the pandemic, we were seeing a lot of caregivers across all of the disciplines really struggling to deal with all aspects of COVID. This is a new disease, we didn’t know how to treat it, we didn’t know its pathogenesis. It strained our workforce from points of treatment, points of caring because these patients are in isolation. A lot, or most, facilities had restrictions on visitation, which hampered family communication. Then of course there was also the political divide regarding the pandemic. All of this together caused a lot of strain and, I’ll say it, it caused burnout and PTSD in our caregivers.

What we saw was that a lot of individuals in the healthcare field were analyzing whether this was still something they wanted to continue to do. Is this the career they wanted to continue for the rest of their lives? The data from various surveys showed that up to 50% to 60% of ICU caregivers were experiencing burnout and, in fact, were ready to quit in the next year, and we did see a lot of turnover, and most of that turnover was in the nursing field. Almost 30% of nurses turned over. But it’s not just the nurses. Pharmacists had a high level of burnout and turnover and so did advanced practice practitioners. So, thinking about it situationally, but we also have to think about what the impact of these experienced individuals have when they leave our healthcare system.

Dr. Madden: I know, at least in my environment, all of those statements are true, but another group that’s part of the ICU team, our respiratory care providers, really, really were impacted as well.

Dr. Chavez: Definitely. I can echo the respiratory care, I work very closely with that department, and seeing that they’re losing their longevity, and also how many people are coming into the respiratory care discipline is another factor that played into that. Changing with that time and trying to address how we can improve getting people into the respiratory therapy programs and how we can retain the ones that we have now. I’m seeing that with nursing as well. The amount of people leaving, you’re seeing this all over the place and it’s due to all those factors that were just stated.

We have to look at innovative ways of how we can retain, including giving our clinicians resources that help with mental health, addressing that PTSD because that’s something that we need to look at as far as the innovative approaches of how we can retain these nurses, physicians, respiratory care therapists, any of the ICU clinicians, and addressing the healthcare work environment. I think that a lot of attention is now starting to go toward healthy work environments and how we can implement that into our settings and getting people on board, getting our champions, getting people in the C-suites to understand how important the healthcare work environment is.

Dr. Madden: All of this, for anybody who’s going to listen, it’s going to resonate. Tell me, have you seen some of these areas already be focused on and have some strategies being implemented? If yes, any success with it? There’s no magic bullet, we know that, but everyone’s very cognizant of the stress that the system’s under and how crucial it is to have trained, happy, positive clinicians in our environment because it impacts us as a team, but certainly it goes to our patients and to our families and to their outcomes. So, love to hear what strategies or thoughts the committee has been working on at SCCM or, as I said, you personally as clinicians.

Dr. Chavez: I have actually seen good movement toward addressing this. This comes from the studies that have been seen coming out and they are addressing staffing, quality of patient care, and even the studies of the critical care collaborative. All of the organizations that address critical care are coming together and addressing this and more so locally. I have seen healthy work environments through the AACN working with different organizations. That is just a start, and I do see it starting to head that way as far as what can we do. It’s going to take more energy, but this is a start. I feel like just the studies that have been coming out, the attention that’s been going toward the environment, and it will start to make a difference and I have that faith.

Dr. Madden: Dr. Reddy?

Dr. Reddy: I think one of the things that a hospital or hospital system doesn’t always consider is the impact of turnover or the lack of retention. We see that, not only is there a cost associated with turnover, but there are also very specific patient safety and quality metrics that are affected by turnover, and oftentimes what we’re seeing is that turnover is leading to a less experienced workforce. We know that, when we have turnover in all of the different disciplines we had mentioned, there are consequences such as increases in medication errors, increases in falls, increases in healthcare-associated infections such as CLABSI, CAUTI, VAE, surgical site infections. Individuals aren’t as familiar with the quality and safety protocols, which then can hamper care.

Then, as you mentioned, Maureen, a happier workforce also leads to a happier patient and family. They tend to do their job better. I think this is something to definitely mention and put in the minds of those who are trying to retain their workforce. It’s not just a position to fill, we have to appreciate the experience across all of these disciplines.

Our institution has worked on reducing nursing turnover and RT turnover the most. Though many institutions are strapped for offering higher pay, certainly institutions want to match pay in that particular geographic area, that particular level of acuity. But our institution is also trying to focus on advancing those individuals’ careers. So, if there’s a particular individual who wants to get a higher degree, we help defray the costs of, say, a nurse wanting to get their master’s or their doctorate.

We have opportunities for building skills, whether it’s skills in leadership, skills in education, and we know that having these types of programs available allows the caregivers to have a more meaningful career. They don’t feel like they’re just pigeonholed into one aspect of their job. Not only clinical care, but there are various aspects that they can also participate in.

Dr. Madden: It’s interesting to think about, and I come from a background of nursing as well. Jose had mentioned AACN, the American Association of Critical-Care Nurses. They’ve been leaders in the concept of a healthy work environment for years and they’ve re-looked at it. It’s about communication and respect and resources and several other components. They’ve been really championing this and had a very strong voice.

The collaborative is an incredibly strong voice as well for critical care. Do you think the reaction right now is in response to the pandemic or has it been building? Because there’s been lots of discussion for years about the nursing shortage, that it was here and it was going to get worse. There wasn’t, to my mind, very public conversation about the lack of positions for respiratory therapist training, and then, therefore, in the pipeline. I recently had done something, and the development and training of physicians is pretty flat.

It’s the advanced practice people, in terms of both nurse practitioners and PAs, that they’re having growth. The pharmacists also are pretty flat in who they’re graduating. How do we really address this? Is it really the pandemic that became the point that drove this home? Because all of a sudden, we saw people leaving when they were not anticipated to leave.

Dr. Chavez: I think it was a growing problem. The pandemic just multiplied it. You just saw that resulted in a much higher magnitude. Addressing the retention is now different. We knew that this was a problem and the work has been more significant, and now we’re in a point of, like, how can we retain with innovative ways?

Dr. Reddy: Yeah, completely agree with both of you. I think it was something that was creeping up and just the pandemic blew it out of the water, and I think there were a couple of things that go along with it. We’re seeing less reimbursement from insurers. We’re seeing a lot of supply chain challenges on top of all of this. Our folks in medicine see that they can possibly go to an equally paying job where they could be happier and not so burned out or stressed out about doing more with less. I think all of this kind of ties in to retaining our caregivers and making sure we’re maintaining that quality and safety aspect for our patients and their families.

Dr. Madden: So true. I mean, I’ve made the comment, we all have acknowledged that people are leaving and they’re leaving because it was close to retirement time. Then there were those who left ahead of anticipated retirement and then I’m like, where did they go? You made the comment that they could find better in terms of work-life balance. We’ve also thought about the newer, younger individuals coming into these professions and truly looking at the value of work-life balance and the cost of training, both in time and money.

What is it that you’ve seen that has been successful in the short term that’s keeping them retained and in place? Dr. Reddy, you talked about giving people opportunities for advanced education, but that’s only going to go so far, and it almost creates a similar problem because the education often puts them in different roles.

Dr. Reddy: Absolutely. I think you’re very, very smart to point out that there is an interest in this work-life balance. We know that, as we cross generations, we have to be more creative in how we retain caregivers. Is it different types of schedules, so different types of shifts, allowing our caregivers to balance that home life and their work life? I think a lot of individuals across the board, across the disciplines, want to work at the level they’ve been trained for.

This verbiage of practicing at the top of their license and making sure they are appreciated and recognized for the work they do, I think you mentioned that earlier. That’s in addition to the, say, career development we had talked about before. But it’s hard to develop your career without a mentor. So, if you want to have some sort of aspect of your career emphasized or educated more in that area, you have to have good mentorship, someone who’s willing to put in time and advice and, again, appreciation for the work that you do. I mean, I’m not going to say that pay isn’t an incentive, but I think pay alone is not going to keep our caregivers in our healthcare system.

Dr. Madden: No, it probably won’t, because I don’t think people entered all of the different roles that we have in the different disciplines because of the money they were getting. There are certainly higher-paid professions. But you touched on a point of work-life balance. Historically, using nursing as an example, the classic shifts were similar to some other industries that have a 24-7 cycle, that there were three shifts. They worked eight hours and people discovered that was not as much as a satisfier.

So they made this shift now to these 12-hour shifts. And there’s a lot of research out there that actually shows it benefits the nurse but it doesn’t necessarily benefit the patient. And here we come full circle because we’re talking about quality and safety for our patients. How do you see some of that work-life balance that would retain our professionals in the intensive care unit but still balancing it with quality and safety?

Dr. Chavez: I was at a conference recently and I was at a table discussing this same topic with some bedside nurses from another organization. They worked at multiple organizations in the local area. One of the biggest things that they brought up was their work-life balance and the way that those different organizations provided shifts for them. Some of them were very strict with not a lot of flexibility. Then the other had a lot of flexibility.

I think the leaders for every organization and for the critical care units have to be able to listen to their staff because it may not be the same for every organization as far as the way they do their shifts, but they can listen and they can address the biggest concerns. Doing that, you address their work-life balance. The nurses become happier. Specifically, there was a table of like 10, and about seven of them expressed the same thing as far as the flexibility has definitely been a factor in happiness at their organization, so I think that the flexibility and working with the staff and making sure that their work-life balance was addressed.

Dr. Madden: I’ve heard people had talked about even just childcare within the relatively close environment of where the work is. We used to have some of that. Some places still do, but there are a lot of drivers behind that. There are a lot, I think, of really smart people who can be looking at this and maybe come up with some concepts about how we can move that forward.

I want to go back to a comment that, Dr. Reddy, you made in regard to the long-term benefits that, when we have all of these turnovers where people don’t stay very long, it’s not just the monetary piece that the organization has to invest in human resources, but how do you gauge that someone who has had years of experience, that they have knowledge of the systems, they have knowledge of the technology, and it comes from every single discipline, that’s all there, that’s going to drive a lot of that quality and safety. How can we do that?

Dr. Reddy: I completely agree. It’s having the experienced caregivers with, say, their longitudinal day at a particular institution. It’s not only their experience of current protocols, etc., current practices that helps with patient safety and quality, but it’s also their knowledge of what’s been tried in the past, what worked, what didn’t work. They can weigh in on all of that so you’re not re-creating the wheel over and over again. I mean, I am certainly not an expert in solving these problems, but I think some of the things that the Cleveland Clinic has done, as I mentioned earlier, in terms of opportunities to advance career, but they’ve also talked to our caregivers about what do they want to see in terms of benefits.

Our employees actually get a chance to say which benefits they want to partake in. Say, for me, since I have a minor child, one of my benefits may be helping toward daycare, camps, etc., whereas someone who does not have a child may elect to have other benefits related to time off or vacation time. As Jose was mentioning, you can concentrate on the areas that are more valuable to you. Having the flexibility, not only in terms of your schedule, but flexibility in terms of what benefits you may want, I think will help with retention as well.

Dr. Madden: I’ve really enjoyed speaking with both of you. I think that maybe we’ve teed it up for a lot of the conversations that will follow in the next episodes. But before I have to close it out for us today, is there anything else that you wanted to bring up before we conclude?

Dr. Chavez: What I’d like to bring up, for those who are listening and those who are interested, is to put some energy behind this. Contribute to the studies, help contribute to reaching out to lawmakers, contribute to improving what’s going on now, putting energy into this force.

Dr. Madden: Dr. Reddy, any thoughts that you’d like to express before we conclude?

Dr. Reddy: Thank everyone for listening. I think that the executive leaders who are listening to this podcast, please, please remember, as you emphasize quality and safety for our patients and get our caregivers on board with ensuring the highest-level of quality and safety, that retaining our caregivers is one of the principal ways to ensure that that occurs.

Dr. Madden: Thank you both. I really appreciate your time and your enthusiasm and your expertise. This concludes another episode of the Society of Critical Care Medicine Podcast. Don’t forget if you’re listening on your favorite podcast app and you liked what you heard, consider rating and leaving a review. For the Society of Critical Care Medicine Podcast, I’m Maureen Madden.

Announcer: Maureen A. Madden, DNP, RN, CPNC-AC, CCRN, FCCM, is a professor of pediatrics at Rutgers Robert Wood Johnson Medical School and a pediatric critical care nurse practitioner in the pediatric intensive care unit at Bristol Myers Squibb Children’s Hospital in New Brunswick, New Jersey.

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