How to Fix the Nursing Shortage and Address Burnout: Veteran Nurse Leader Has the Answers

by Renee Hewitt | Sep 12, 2023 | Blog, Burnout, Critical Care Nursing, News, NPs, Nurse educators, Nurse Staffing Shortage, Patient Care | 0 comments

Dr. Anne Dabrow Woods has incredible insight into nursing as a practicing critical care nurse practitioner and nursing educator with over 39 years of experience and counting.

Amidst a sea of temporary band-aid solutions for nursing, like gig apps and travel nurses, Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN, the Chief Nurse of Health Learning, Research and Practice, Wolters Kluwer spoke with Daily Nurse to discuss her practical, long-term solutions to address the nursing shortage and burnout. What follows is our interview, edited for length and clarity.

How long have you been in nursing, and what are some of your roles during that time?

I’ve been a nurse for 39 years and a nurse practitioner for 25 years. I’ve worked as a staff nurse, nurse educator, manager, and director of different critical care in hospitals, and then I went on and became a nurse practitioner. As a chief nursing officer, developing the right resources for nurses and other clinicians in education, practice, or research is imperative, so I’m out there doing it. As a critical care NP, I work weekends for Penn Medicine Chester County Hospital and teach undergraduate nursing. About ten years ago, I flipped over to working in graduate education at the master’s and doctoral levels for both Drexel University and Newman University as adjunct faculty. So, I wear different hats. I know what nurses need in practice. I’m a nurse practitioner, but I always work alongside nurses. I work in critical care, so I have my doctorate in nursing, a master’s degree, and a post-master’s certificate. And I’m a fellow in the American Academy of Nursing, so it’s just doing what I love.

You can talk about it because you’re living it.

What gives me street cred for people when they talk to me is that I know what’s happening out there and living it through what I do with nursing education, but also what’s going on in practice today. There are a lot of things in practice we have to change. There are going to be few nurses left at the bedside to care for patients. We’re on the precipice right now. We can change things for the better if we play our cards right.

There are several temporary solutions to address staffing shortages and burnout, like gig apps and traveling nursing. What insight can you share about practical, long-term solutions to the nursing crisis?

In travel nursing, you have an app to sign up for any shift you want, but they’re all band-aids. The more significant problem is we have a nursing shortage, and we knew it before we went into the pandemic. Then, post-pandemic, we’re seeing the effects that many more people either retired or decided to leave the bedside and go into other roles. Or some people left the profession together. So, what we anticipated with the nursing shortage coming in 2030 has hit us sooner than that. These quick, short solutions that people talk about, you hit the easy button, and they think it’s going to fix things, and it’s not. 

The bottom line is we have to increase our pipeline, which is an issue right now. And we need to ensure that the nurses graduating are practice-ready because they are not. We need to understand most nurses in acute care and long-term care settings now are novice nurses or nurses who have only been in the profession for a few years. So, the fact that we have less experienced nurses at the bedside is problematic. The other big thing we’re seeing is that nurses in the age group from 25 to 35, which should be who we are relying on over the next 10 to 20 years, are starting to leave the profession because they are very burned out. They’re unhappy and need to see healthcare organizations addressing the pitfalls that we’re seeing with staffing. So they’re deciding to leave. We need to do some things, not only in academia, to make sure our nurses are practice-ready, but we also need to make sure in practice that these new graduate nurses coming in are supported and trained so they can become competent. We need to make sure that we support them through more extended orientation programs or nurse residency programs. Then, we always have people available to the newer nurses as their support system or resource. And a lot of healthcare systems still need to invest in that.

The good news is they are starting to understand the importance of a resource nurse position to help these newer nurses when they have questions. But we need to fix this right now. And this means different care models, too. So before the pandemic, we had this primary nurse model, which we’ve been practicing for 25 years, where one RN took care of four, five, maybe six patients. Then the pandemic hit, and you have many more patients and nurses. So we switched to this team model where you had a more experienced nurse who oversaw the care that less experienced nurses delivered. So we now know, post-pandemic, that we can’t stay in the primary nurse model anymore. We have to use the team model as an alternative care model because there are not enough experienced RNs.

Can you discuss how a team-based nursing model can help offset today’s nursing shortage?

We’re redefining the work of nursing. Before, in the primary nurse model, the nurse did much of the patient’s care. In a team model, the nurses oversee the care by unlicensed assistive personnel. So people like certified nursing assistants or patient care techs will do many hands-on activities of daily living like bathing, dressing, and other things. So that’s what the team model does. It allows you to have one very experienced RN overseeing several less experienced nurses and the work of your unlicensed assistive personnel. It means you can care for more patients, yet you still have one experienced nurse overseeing everything. They won’t be in there doing the baths as much and that type of thing. They’re going to delegate that to other people. But we have to do that to care for our patients appropriately. And it doesn’t mean that the care of patients will suffer. If you put the model in place correctly, it means that the work of nursing will be more defined as someone overseeing, directing, and delegating the care. Of course, the RNs only have things they can do in their scope of practice. And they will continue to do that. But it means that the team leader will do a lot more delegation. So we’ll still have quality care, but all RNs won’t do it. Other people will do it.

What problems must be overcome with the team model of nursing?

I’ve been a nurse for 39 years and was taught the team model of care. But if you graduated in the 80s into the mid-90s, you learned the team model of care because that’s what we did. And then we shifted over to primary. So anybody who’s graduated in the last 20 years needs to learn the team model of care. The graduate nurses need to understand what it is, too. So, when the pandemic came, we had to switch from the primary nurse model to the team nurse model. We had to re-educate people quickly on working within a team model of care and how to facilitate delegation.

But most importantly, we had to facilitate the correct communication so patient care doesn’t suffer. We can drive quality patient outcomes. So that’s part of it. We have to educate people. And academia has got to start educating people as well. And they are now aware of that. Many programs are starting to include alternative models of care.

During our recent nursing strikes, you’ve discussed the importance of revealing systemic issues healthcare must address. Can you talk about how nurse-specific billing data makes nurses literally and figuratively invisible in terms of political and financial decision-making capacity within the U.S. healthcare sector and what we can do to overcome these issues?

Physicians and nurse practitioners, like myself, can bill for our services. So, whatever we do, we document it and get reimbursed. I work in acute care, so I never see a reimbursement because the hospital sees the reimbursement. So, nurses are looped in with the room and board charge for the patient. So, there is nothing that financially defines the value of nursing because they don’t bill for their services. Now, we can look at outcomes data. And we do know that if you have fewer nurses, your patient outcomes will suffer. There’s an increased mortality rate and all of that. The best way for us to show the nurses’ value and give them a voice is to quantify their value and what nurses bring to the healthcare system. If we can get to the point where nurses are reimbursed for what they do with patients, we’ll see the value of nursing. We look at patient outcomes, and that type of thing, but the fact that nurses are looped in the room board charge is ridiculous to me. The chief financial officer will clearly understand nursing’s value once we’re moved over to the other side of the ledger. So that’s where we need to get to now. Nursing informaticists and healthcare organizations are analyzing the data to see what we can pull out of the EHRs to demonstrate the value of nurses and what they bring to the healthcare setting and show if you don’t stop at a certain level, based on the nurse competency and patient acuity, you’ve worsened patient outcomes. And it’s going to cost the healthcare organization X amount of dollars. But we need to go further than this. And that’s why we need to see if we can get nurses to bill for their services.

The nursing workforce is 50 percent of a healthcare institution’s expenditure, and when trying to balance the books, they will look at their biggest costs. Nursing is taking up the most significant amount. So they start to chip away at it, which gets us into trouble. We will only stop that once we can demonstrate and show the evidence that what we do as nurses does make a difference. And we can tell you how much of a difference that is financially if nurses were able to bill. That’s where we eventually get to, and I don’t know if I’ll see it in my lifetime, but that would solve many of the issues.

Change across healthcare in the last few years requires a new path forward for nurse staffing and care models. How should nursing be optimizing recruitment, retention, and care models post-pandemic?

People always look at how much we pay a department and then ask what they produce. What is their output? You’re not aligned. You’re just constantly roped in with room and board. Healthcare is a business, and every business has to show a return on investment. If you invest in a group or a product, you need to see what the organization gains from it. If nurses bill for their services or are recognized for everything they bring, you can see that it’s worth investing in nursing to get a higher return. You’ll get better patient outcomes. You’ll get better reimbursement from Medicare, the big blues, and everybody else in insurance. But we have to invest in our nurses. That’s the secret here.

Everybody is focusing on recruitment. We have to recruit more but then recruit these new nurses who need to be more competent, and many need to be practice-ready. But you got to train them. You can’t just leave them floundering after you finish training. So that’s where the nurse residency comes in. The latest stats show the turnover rate is 22.5 percent. And for new nurses, it’s 33 percent. New graduate nurses leave within one year because they do not feel valued. So healthcare organizations that invest in training invest in large residency programs, which means they’ll be in orientation for six months to a year, and their turnover rate is much lower. But it’s not just about recruitment. We must retain our talent within our healthcare organizations and make every nurse feel valued.

We need to pay nurses what they’re worth. When you look at all the reasons people leave and what they want, and even the striking nurses, which I’ve talked a lot about, and ask them why they leave, of course, they mention salary. But the real reason is staffing because there are not enough competent nurses at the bedside. And we still insist on staffing by numbers and ratios. And we can’t do that anymore. We have to look at what is the competency of the nurse. And if they have the skills to care for the patients in that specific unit. So it’s the competency of the nurse, but also the patient acuity. So, ten years ago, if you had a 20-bed unit, you could get away with having four RNs. It will take a lot of work with patient acuity and nurses being less experienced today. You’re going to need better quality care. You have to look at all that, and you’ll have to step higher. So we look at competency-based staffing, which looks at the nurse’s competency, the patient acuity, the numbers, and what people consider safe. But you can’t just look at numbers alone. And that’s where we need to get to. Healthcare organizations must start investing in the nurses there to help them with training and help them move up in an organization or laterally to different roles. People would stay, but they don’t feel like they’re being invested in and burned out because more nurses are needed to work beside them. They’re going to leave, and that’s just the reality of the situation.

Should we encourage nurse leaders to talk more with nurses to learn about their concerns?

Nurse leaders have to get out of their offices. They must be up on the units, talk to the people at the bedside, and talk to their managers. We’ve talked a lot about the staff. We also have to think about that middle management layer, the nurse managers. Those people are leaving as well. We need to ensure that they are adequately trained to assume the competencies of the nurse manager role. The organization’s CEO, CFO, and directors must be up on the units visible. I talked to the people working to see the real issues and asked them what would help them. The big thing is that we have to change culture right now. And the best way to change culture is to get out there if you’re a leader and see what’s happening within your organization. So it’s about improving that communication, getting out of the office, walking the walk, and talking the talk. Or talking the talk, walking the walk, you have to be able to do both.

I work for Penn Medicine, Chester County Hospital, and we see our leaders on the floors. And I work weekends, and they come in on the weekends. And that is great. I won’t say we don’t have issues because we do like everybody else. They struggle sometimes with staffing, but the fact that our leaders are present, they see what’s going on, they hear when people say, “Look, we can’t do this anymore.” They listen. And that’s what all organizations need to do. If leadership is listening and provides the staff with the right resources, like information tools, that type of thing they can use in their practice. But changing the correct number of competent nurses is vital because they’re investing in the workforce.

Will new staffing models, partnerships with academic institutions, and being more mindful of techniques help retain workers and solve the staffing crisis?

That’s good and going to help. One thing to remember is they can’t do it by themselves. Academia can’t do it alone, and we have to work together. We cannot be in our silos anymore. We need help. When you look at enrollments in nursing programs around the country from undergrad, bachelor’s, master’s, and doctoral levels, all enrollments are down over the last year. So people look at our profession and say, “Wow, I don’t want to be a nurse.” Because they’re talking to nurses who say, “I’m exhausted.” We’re going to change that, but we need to start. First, we should be working with high school students when they decide what they want to do with their life. So nursing is challenging and can be hard, but it’s also so rewarding. And if we work together, then we can make change happen. It’s about ensuring we fill the pipeline and educating people correctly. The NCLEX test just changed in April to focus on clinical judgment, which is what every nurse needs to be able to use in their everyday practice. I’m excited they decided to do this because it will make these graduate nurses more practice-ready. If they graduate, pass the NCLEX exam, and get into practice, we need to support them because they’re just starting to understand clinical judgment. We need to foster and facilitate that education, even when they’re in practice, by giving them the training and skills they need. So when they get to be three years out, five years out, they’re truly competent nurses who could then help with the next group of new nurses coming in.

We have to work together, get out of these silos, talk to each other. We have to pay faculty more. The age range is higher than a staff nurse’s, so many are retiring. We need to get people in nursing 10-20 years to think of becoming faculty. They want to stay in their staff position because they get paid much less, so we must address faculty salaries. We need to ensure they have adequate resources in schools, like more simulations, and invest in adjunct faculty. So, somebody like me, I don’t work full time as faculty because they can’t pay me enough. I know how to teach because I was trained how to teach. We need to train nurses who are hungry and excited to want to help and teach them how to facilitate learning. And we need to do more of that.

I’m just doing what I love. I’m a nurse, and I love this profession. When you’re in it for a while, it’s our responsibility to give back to the profession. So, I do all these things because it’s my professional responsibility to do that. But the truth is, I love everything I do.

We’re at the best time in our profession because people are listening to us. And we have the ability, if we speak with one voice, to get the things we need to improve with great opportunities ahead for all of us.