SCCM Pod-491: Nursing the Wounds of Burnout

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COVID-19 transformed healthcare and presented specific long-term challenges for the nursing profession. Samantha Gambles Farr, MSN, NP-C, CCRN, RNFA, was joined by Norma J. Shoemaker Honorary Lecturer Ernest J. Grant, PhD, RN, FAAN, at the 2023 Critical Care Congress to discuss the shortage of critical care nurses. Survey results reveal that nurses continue to experience burnout and frustration. They discuss how to leverage data to best support nurses now and in the future.

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Transcript:

Dr. Gambles Farr: Hello, and welcome to another edition of the Society of Critical Care Medicine Podcast. I’m your host, Samantha Gambles Farr. Today, I will be speaking to Dr. Ernest Grant, the Norma J. Shoemaker Honorary Lecturer. Welcome, Dr. Grant.

Dr. Grant: Thank you for having me.

Dr. Gambles Farr: I just wanted to take a moment and introduce you properly. Dr. Ernest Grant is the immediate past president of the American Nurses Association, also known as ANA, the world’s largest nurses organization, representing the interests of the nation’s 4.3 million registered nurses. He is the first man to be elected to the office of president of the American Nurses Association in its 127 years of existence. Quite a feat. A distinguished leader, Dr. Grant has more than 30 years of nursing experience and is an internationally recognized burn care and fire safety expert. He also serves as adjunct faculty for UNC Chapel Hill School of Nursing, where he works with undergraduate and graduate nursing students in the classroom and clinical settings.

For the past four years in a row, Dr. Grant has been recognized by Modern Healthcare Medicine as one of 50 influential clinical executives in healthcare and as one of 100 most influential people in healthcare. In 2002, President George W. Bush presented Dr. Grant with a Nurse of the Year Award for his work treating burn victims from the World Trade Center site. He was inducted as a fellow into the American Academy of Nursing in 2014. Dr. Grant holds a BSN from North Carolina Central University and MSN and PhD degrees from the University of North Carolina at Greensboro. Welcome, Dr. Grant, and thank you so much for this immense honor of being able to host this podcast with you today.

Dr. Grant: Well, thank you. I’m delighted to be here. After that long introduction, I don’t know if we’ll have enough time.

Dr. Gambles Farr: It’s a well-deserved, hard-earned, hard-fought introduction. We are all just so thankful to have you here. Today we’re going to talk about the nursing shortage in the country, especially how that relates to what happened pre-pandemic, but especially what has happened post-pandemic. Before we start that, I just wanted to ask you if you had any disclosures you wanted to get out of the way.

Dr. Grant: Thank you for asking. I have no disclosures. The only thing I guess perhaps is just, in my role as president of the American Nurses Association, we began to tackle this issue, but as far as financial or any other compensation, no.

Dr. Gambles Farr: Thank you so much for that. So, the burning question everybody wants to know: Why are nurses leaving?

Dr. Grant: Oh, that is the 64-million-dollar question. Nurses are leaving for a number of reasons. As I’m sure a lot of listeners would recognize, this shortage is nothing new. This was predicted years ago. We as a profession and we as members of the healthcare team all together failed to heed the warnings that were coming along. Of course, as more and more nurses began to retire, particularly baby boomers, they failed to replace them. We’re only graduating about 250,000 new nurses per year in the United States.

When you stop and think, when the pandemic occurred we were already short about half a million to a million nurses, it’s hard to backfill that hole when you don’t have enough nurses to replace the ones who are retiring or choosing to go to either another profession or just choosing not to work in nursing altogether.

One of the other things that we need to take into consideration as well is, when the pandemic happened, a lot of older nurses, if you remember when the pandemic happened, it was the older people who were affected first, and a lot of older nurses decided that, “Well, I’m going to go ahead and retire now because I don’t want to take the risk of either contracting this virus,” because again, in the first few months, when it hit the shores of America, we had no idea how it was spread. A lot of nurses felt, “Well, I don’t want to take this chance of either contracting it or worse yet, bringing it home to my family.” So a lot of older nurses retired in droves, and that too led to a significant shortage.

We also have a lot of younger nurses who perhaps do not want to remain at the bedside. They go on to become either advanced practice nurses, which there’s nothing wrong with that. I applaud them for wanting to do that, or perhaps they want to branch out away from the acute care setting as well, and that too contributed to the significant shortage that we’re seeing.

Finally, the last thing is there’s not enough nurse faculty. There are a lot of people, as I’ve traveled the country over the last four or five years and talked with deans and directors of nursing programs, they will say, “Oh, we have a waiting list. But the problem is we don’t have enough faculty. We’re doing everything we can to try to turn out more nurses, offering classes at nights, offering classes on the weekends. But you have to have enough faculty to do that and enough clinical space for those individuals who want to become nurses as well.” Sorry for the long answer, but that’s what it takes to get people to understand that this has been happening for quite some time.

Dr. Gambles Farr: Yes, it didn’t just happen overnight, for sure. Just as we knew that it was coming down the pipeline that we were going to have these nursing shortages, was it easy for us to predict where those nursing shortages would be hardest hit in certain regions, specialties, as it relates to nursing?

Dr. Grant: Well, it has hit everywhere equally. But obviously, depending on which latest study that you read, one of the last ones that I saw said that the significance of the shortage was mostly in the southeast. When you look at the heavily populated sections of the country, and especially the major metropolitan places where you wouldn’t expect to see large employment of nurses, if you think of Atlanta, Charlotte, Washington DC, New York City, those are places that are really experiencing the shortage significantly. Specialty areas, obviously the intensive care units, the emergency departments and, of course, let’s not forget about long-term care as well, because remember during the pandemic, there was a shift with the shortage of registered nurses in the acute care setting. Hospitals began to hire LPNs back from long-term care, which obviously, the domino effect is that, “Okay, now, we’ve created a shortage of LPNs in long-term care,” so they too are suffering.

Dr. Gambles Farr: In thinking of how the pandemic played a detrimental role in the nursing shortage, one of your colleagues, Dr. Katie Boston-Leary, the ANA’s director of nursing programs, gave a very descriptive analogy of the Titanic syndrome. Can you describe what the Titanic syndrome is?

Dr. Grant: Certainly. The Titanic syndrome more or less relates to the fact that we know the ship is sinking or, in this case, we knew, as I stated earlier, that the shortage was coming, but we didn’t do anything about it. We sat there, continuing to play the fiddle, if you will, and hoping that somebody would come and rescue us, put us in the life rafts and rescue the situation. It just isn’t happening because what we’re seeing is it’s causing more and more nurses to leave the profession.

Actually, a lot of nurses aren’t leaving the profession, they’re just choosing not to work in the conditions that they’re being asked to work in, that is, obviously having large patient loads, working long hours. Normally, a 12-hour shift is now a 13-, 14-, or 16-hour shift. Nurses would tell me, when it’s their day off, they have to unplug their phone because their employer is calling and begging them to either come back to work or shaming them into coming back to work at least for a few hours to help them out.

To get back to the analogy of the Titanic, it’s the same situation. While the fiddlers are playing, no one is really getting enough people into the lifeboats. In other words, we’re not being thrown a lifeline to help stop the leakage that is happening or nurses who are saying, “This is the last straw. I can’t take this anymore. It’s not only detrimental to my health, both mentally and physically,” but they also see that they’re not able to provide the best patient care, and it’s the patient and the consumer who is suffering as a result of that.

In some cases, nurses will say, “I got dinged because I felt it important to spend time with the patient instead of going back to the electronic medical record and checking these boxes, stating that I did or did not do something.” It’s hard for nurses to want to do the care that they want to do when they may be reprimanded because they didn’t check something on the electronic medical record.

Dr. Gambles Farr: Yes. The electronic medical record definitely has its pros and cons.

Dr. Grant: Yes, it does.

Dr. Gambles Farr: It’s organized the way that we do things, but it also has tethered us to that. At times, it does take us more and more away from patient care. As it relates to addressing the issues of nursing shortages and nurses leaving the profession, are there any organizations that have made strides as it relates to this?

Dr. Grant: Yes, absolutely. The American Nurses Association, the American Association of Critical-Care Nurses, HCFA, AONL, some of the payers as well. We have a workforce task force where we are looking at some of the drivers, what are the issues, and coming up with a game plan. One of the first things that we did was to hold listening sessions and find out what it is that is really getting to nurses, that is making them want to either leave the profession or, as I said, just choose not to work. The number one thing is they want a safe working environment. In other words, what we mean by that, that could be taken from two or three different perspectives.

The first thing is, obviously when you think of a safe working environment, that means having enough nurse-patient ratios or enough nurses to provide the care that needs to be done, maybe not necessarily ratio, but at least enough people to provide the care that needs to be done. The other thing is you want a safe environment because daily we’re hearing that nurses are assaulted by patients or patients’ families or even their colleagues. You can’t work in an environment like that. You go to work thinking that you’re going to help your fellow man, not that your fellow man is going to turn on you and either strike you or, worse yet, kill you.

As we know, just recently in the news, two nurses in Texas being shot to death, a nurse in my own home state of North Carolina being stabbed to death, and a nurse in Seattle, Washington, being shot and killed as well. These are just people who are going about their business, doing their job, not anticipating that they would not be coming home as a result of what’s happening there. So that was the number one thing, a safe work environment.

The other was obviously pay coming into play there as well, that nurses should be compensated for what they are worth. I truly believe that that’s extremely important as well. There are a few other things there, such as diversity, equity, and inclusion, the chance for advancement or for leadership skills, etc. But the number one thing is the safe work environment and nurses feeling valued. Value to a younger nurse, I’ve been in nursing, in your introduction you said over 30 years, it’s actually about 40, but we say 30 to make me seem younger, but I’ve been a nurse for 44 years, and we’ve been through a number of these nursing shortages, but nothing like this.

In fact, in September of 2021, I wrote a letter to HHS Secretary Becerra asking him to declare this shortage a crisis. It is that significant. Part of it is nurses want to feel valued. Value to older nurses like me is different from a millennial nurse. We need to find out what it is that you need to make you feel valued. What can the employer offer in a way to make you feel valued? Again, for some people, it’s maybe a portable 401(k) or flexible staffing or things of this sort. It’s going to be different for different individuals but at least we need to recognize that a nurse needs to feel valued. For this nurse, this is what value means, and for another nurse, value may mean something else.

Dr. Gambles Farr: I think it’s more important to ask. That the ask actually happens from leadership.

Dr. Grant: Absolutely.

Dr. Gambles Farr: It’s very important. Leading into that, how does the culture of working with not enough safety, not enough staff to help properly care for our patients and our community, how does that impact overall what we’re seeing as far as trends in nursing?

Dr. Grant: It impacts it significantly because, let’s say that if you’re the charge nurse and you’re on a very busy med-surg floor and you call up to the staffing office and you say, “I need one or two additional bodies based on the patient load that we have,” whether the patient acuity or the number of patients that we have. But as usual, you’re told, “Well, there’s no one else that we can send you.” So one of the things that we as nurses have done, traditionally, and continue to do to this very day, is to suck it up and say, “Okay, Sally, you take an extra one or two and, Ted, you take another one or two,” or whatever. So, the assignment that one or two other nurses could have gotten, the nurses who are on that shift will take on an additional one or two patients.

Then, 12 hours go by, and the next shift comes on, and it’s the same situation. They call up to staffing and say, “We need some additional staffing,” and they may need it even more because usually we staff for more nurses on days than we do on nights, so they’re really going to need it on the 7P to 7A shift, but they’re told the same thing. Then they’re also told, “Well, if first shift did it, why can’t you?” Right? So, we just continue to perpetuate this and it becomes an expectation that when you call for assistance, they’re going to always say, “Well, we’ll tell them no, and they’ll make do.”

The problem though is that it becomes an expectation that you’re going to take on more patients, and that, we know, leads to potential greater omissions or commission errors and could be very detrimental as well. So the significant thing there is that we need to be able to say, “Stop. Wait a minute. Is this safe? Do I feel safe taking care of more patients than what I should? It’s my license that’s on the line and maybe I want to have a conversation about what are some things that I need to be able to do. Can I ask for safe harbor or whatever to finally begin to put the brakes on this? I understand that perhaps administration may be trying their best to find help to come in, etc., but something really needs to be done. Otherwise, it just continues to perpetuate and it becomes an expectation and it shouldn’t be that way.

Dr. Gambles Farr: Right. Not only that, but when we talk about detrimental, we think of our patients, of course, but also what is that doing to the nurses themselves as far as self-care, mindfulness, rest, all the things that we think of, a sense of nurses who work in the community are also part of that community as well. They themselves are also needing the same compassion and understanding and time to rest and spend time with their family, just like the patients we care for.

Dr. Grant: And we know when they don’t do that, then it begins to show both physically and mentally. They’re not eating right. They may find themselves drinking alcohol more. If they weren’t maybe having one or two drinks a night or the blood pressure’s going up, and they get those headaches, etc., or they become very cranky. We know that, even if they recognize it, and we’ve got a lot of mental and physical stress but, from a mental perspective, if they try to seek mental health, there’s the stigma associated with that from a couple of angles. One, if it’s on their license or insurance that they sought mental assistance, that could be a ding against their license.

We’ve been trying to work with insurers as well as the National Council of State Boards of Nursing that, when a nurse does seek mental health counseling, because it may not necessarily be work-related, it could be that, “I’m having spousal problems” or something else, it’s not going to show up that specifically. All they know is that if their state board of nursing perhaps ran a check on their license, if they were seeking employment somewhere else and saw that, “Oh, you got mental health counseling, you’re an outlier,” so you’re going to be wondering, “Can I hire this person or not?” Chances are, they’re not going to want to hire that person just because of that. So we need to change the landscape about that and the stigma associated with that and let people know that it’s okay to take care of your mental health because it’s going to make you that much more of a better individual and that much more of a better nurse as well.

Dr. Gambles Farr: Wow, I just learned something. I had no idea about that. It’s interesting that that would be something that would pop up, especially as we talk about burnout in nursing and in providers and other medical personnel, to have a punitive type of reaction for them in taking care of themselves mentally is, in my opinion, kind of counterintuitive.

Dr. Grant: It is. It truly is. And nurses, just like our military colleagues, you know how you’re expected to be stoic. So, along with the stigma of people finding out that perhaps you did seek mental health counseling, you’re really scrutinized too because it makes you seem like you’re weak.

Dr. Gambles Farr: Right. Be strong. Keep your head up.

Dr. Grant: Right. And we can’t all do that.

Dr. Gambles Farr: Yes. Okay, so where do we go from here? How do we change this narrative? Is it something that we need to do on a local level, state level, preferably a national level?

Dr. Grant: Yeah, all of those. It truly is. First of all, nurses need to feel empowered to be able to be agents of change. Even if it’s at the local level, if you’re part of a governance committee within your hospital or staffing committee or something like that, working in conjunction with the administration to say, “Well, this isn’t working. How about if we try this and we try that?” There may be a lot of trial-and-error things, but at least you are sending the message to administration that, “Hey, we’re concerned. We care about this place.”

Most institutions don’t realize, but if you’ve got an employee who’s been there for five years, chances are that person’s going to stay there. They’re viewing that as family and, when family has a problem, you’ve got to come together and let’s talk it out. It shouldn’t just be one-sided. I think, from an administration perspective, the chief nursing officer, the chief operations officer, the chief financial officer, I’ve always said that doing the town halls is one thing and they’re great to actually actively, and I stress the word “actively,” listen to what the nurses have to say, because it’s going to be different for different units as well, but gather from there.

Also, have that two ways of communications. Letting them know, “Yes, we understand that, we’re short-staffed, and this is what we’re doing to try to alleviate that.” If it means bringing in travelers, in some cases they’re a big dissatisfier, but it’s a warm body that can help to reduce the load for you and someone who’s very experienced with the particular situation or like if it’s in the ICU or the emergency room or places like that, so someone who can help to do that.

But in the meantime, too, these are some other things that we’re doing, so that maybe we don’t have to have that traveler here the whole time. But if we’re hiring more nurses or having some other incentives for nurses to want to come to work here, and then ask them, what do they know. Maybe it’s more flexible scheduling. Some institutions, instead of doing 12-hour shifts, they’ve gone back to 8-hour shifts.

Consider bringing back the older nurses who retired, again, allowing more flexibility with their scheduling, even if it is just, “Okay, if you can come in for four hours or six hours to help just get wound care done,” or to help, if you’re on a med-surg floor or help do other tasks that really need to be done, again, another good way to assist with that. You’re bringing back someone who probably wants to come back to work, but doesn’t want to work the whole 12-hour shifts or, because as I said, the 12 hours turn into 14 or 16. The older you get, it takes longer for someone like me to recover from working those long hours. But there are some potential solutions out there.

The other thing I encourage a lot of the chief nursing officers to do, I encourage the chief nursing officer, the chief operations officer, and the chief financial officer to shadow a nurse, not for a day, not for two days, but for a whole week. Let them experience what it’s like to not get a lunch break, or maybe go to the bathroom once in 12 hours, or to get a true feel of what it’s like to be that nurse on that floor for a whole week, so that when the chief nursing officer goes to the chief financial officer and says, “We need more FTEs allotted for this,” they understand now what you’re meaning instead of just thinking that a nurse is a nurse is a nurse, because that is not the situation.

You have to take into account the experience that that nurse may have, five years versus someone who’s just been out of school six months, what other ancillary personnel that may be needed to provide care as well. What about being able to flex up or flex down depending on how busy the particular unit may become as well? There are a lot of things you need to factor into that, not just the fact that, “Oh, we got a warm body,” and that’s it. A nurse is not a nurse is not a nurse.

Dr. Gambles Farr: From a legislative arm, as far as local, state, or national is concerned, how do you feel about—I’m sure I already know the answer to this—but nurses being involved as it relates to healthcare policy as it’s developed that helps create movement or rules as it relates to healthcare and medicine?

Dr. Grant: Now you’re singing my song. Absolutely. One of the things that I pride myself on my baccalaureate education was, it was instilled in me as a nursing student that if you are going to consider yourself a professional nurse, you need to belong to your professional nursing organization. What I would tell students, I would take that a little bit further and say, you not only need to belong, but you need to be an active member, underscore the word “active” because it’s one thing to have your name on the roll, but it’s another thing to actually be able to go and talk to your legislator at your state house or even in the U.S. House of Representatives or the U.S. Senate about your experiences.

For the 21st year in a row now, nursing has been chosen as the most trusted profession. We have a lot of clout that we need to be able to use to drive change and to get people to see that we are a profession and we should be treated like a profession. We have an evidence-based body of work. We do research. We are involved in all aspects of healthcare. It’s extremely important that people see that and understand that. Part of that is being actively involved in your professional association.

You can go to your legislator and say, “When you vote on this particular healthcare issue, the trickle-down effect, this is how it’s going to affect the people who voted you to represent them, either at the local level or at the state level, or even at the national level, so that they get a better understanding, or even volunteer to be their healthcare consultant because in a lot of cases, that legislator is depending on a legislative aid who probably went to Google and Googled something on this.

Dr. Gambles Farr: Google MD.

Dr. Grant: Or is listening to a lobbyist who has a whole different interest on there. As I said, nurses, if you’re respected in the community, also you’re telling that legislator, “Hey, I’m a member of the community. Yes, I’m a nurse. Again, when you vote on that particular piece of legislation, it affects me and my family as well, and I’m going to be vocal about it and let you know that I either like it or I don’t like it, and here’s why.”

It’s extremely important that we do that, and I understand that working 12 hours, 16 hours, you’re really tired or you want to do something else, but it does take that extra effort to have your voice heard. Because the other thing, what I will tell my students, If you don’t get involved, then someone who is removed from nursing is going to be dictating how your profession is practiced. We already are experiencing that, and it doesn’t make sense.

We’re the only profession, we’re treated as a line item, if you will. We can’t charge for our services. We’re included in the room and board. Who ever heard of that? It just doesn’t make sense that you are a novelty item, so to speak. If a pharmacist can charge for what they do, if a respiratory therapist can charge for what they do, physical therapists, occupational therapists, why not nursing? Why are we included in room and board? It makes no sense whatsoever. Nurses should be able to charge for the work that they do. In a few studies that have been done, it’s actually been profitable for the institution. I know they’re afraid of that, but it actually has been profitable for the institution when they’re able to do that.

Dr. Gambles Farr: Wouldn’t it be wonderful if advanced providers could bill at 100% and not 85%?

Dr. Grant: Absolutely. Studies has shown people prefer to get their care from an advanced provider.

Dr. Gambles Farr: One of my mentors told me a long time ago, and I’ve always taken this with me, if you’re not having a seat at the table, you’re on the menu.

Dr. Grant: Absolutely. So true.

Dr. Gambles Farr: I always take that with me. It’s so great to hear all the things that you’re saying as a battle cry for nurses to step up to the plate, to help mentor, to be as much of the solution as we can be in our own right, while holding other people accountable and actually doing the work to help ourselves.

Dr. Grant: Absolutely. It’s one thing, and I know that there are a lot of nurses sometimes who will become armchair quarterbacks, if you will, and just sit around and say, “Well, it’s not going to do any good to do this or that or whatever,” but it really does make a difference when you use your voice and you show up and you tell that legislator, “I’m a registered nurse and I vote.” We have the same strength, like when you think of the retired individuals, AARP, how strong a voting bloc that they are, there are 4.3 million of us out there, and it doesn’t matter if you’re a Republican, Democrat, or Independent, the main thing is, when you tell a legislator, “There are 4.3 million of me out there” and of course, they’re going to only be concerned about, “Well, of that 4. 3 million, how many of them do I represent?” But you need to show them those numbers as well, because I’m sure there would be some staggering numbers, and they’re going to listen to you. So it’s extremely important that we do that.

Dr. Gambles Farr: If LPNs, RNs, APPs can all join together as one collective voice.

Dr. Grant: Absolutely. One other thing I meant to have mentioned when I was talking about my professors when they were making that comment about if you’re going to be a professional nurse, join your professional association. The other thing that I was blessed to see was that I’m sure, like a lot of your listeners who will be listening to this podcast will say, as a student, we were told to go to the local district meeting, nurses meeting or the state meeting, or even the national meeting.

One of the things that I had the pleasure of seeing was my faculty members being there, and they weren’t just there checking the roll to see who showed up or who did not, they were there at the microphones, they were there chairing committees, they were challenging thoughts and things like that. In other words, they were showing us how it should be done so that it was easier. It was just a no-brainer that, when you graduated, there was that application to join your state nurses association. I’m extremely happy that I did that.

Dr. Gambles Farr: Hundred percent. Well, Dr. Grant, thank you so much for an engaging, reinvigorating conversation. I feel like I’m ready to go out and battle the world. I know that you will continue to do the great work that you started and will continue to complete until our consumers and the people who we really work for and care for, because nursing is a profession of the art, but we are evidence-based providers as well, and if we can just get the consumers to play a role with this and advocate for us as well, I feel like we will all do great things and hopefully this nursing shortage will taper off once again.

Dr. Grant: I hope so too. Thank you very much for the opportunity to speak with you.

Dr. Gambles Farr: Thank you for all tuning in. This is Samantha Gambles Farr and Dr. Grant signing off. Until next time.

Samantha Gambles Farr, MSN, NP-C, CCRN, RNFA, is a nurse practitioner intensivist at University of California San Diego Health in the Department of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery. She also serves as adjunct faculty at University of San Diego Hahn School of Nursing and Health Science in its nurse practitioner program.

This podcast was recorded during the Society of Critical Care Medicine’s 2023 Critical Care Congress. Access essential education online through Congress Digital. More than 120 sessions are available on an easy-to-use platform. Continuing education credit is also available. Some SCCM members receive complimentary access to Congress Digital. To learn more, visit sccm.org/congressdigital.

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