As hospitals and post-acute inpatient facilities in some parts of the nation begin to come out of the darkest days of the COVID-19 pandemic and start shifting toward a “new normal,” there are important lessons learned that can be carried forward. Healthcare-facility operators should recognize that their employees are part of an overburdened workforce that has been under immense stress — and they can act accordingly to promote and preserve staff well-being. Healthcare employers who respond by designing and implementing systems, tools, processes, and workplace environments that support their staff can better help them meet the ongoing challenges posed by the outbreak and its aftermath.
As essential employees thrust into the frontlines of the fight against COVID-19, nurses, licensed practical nurses (LPNs), certified nursing assistants (CNAs), and all other employees working in hospitals and post-acute facilities around the nation have been operating under unprecedented conditions for several months, battling not only the virus itself, but also fears for their own health and the stress of doing a job that, at times, seemed never-ending. From early challenges to secure enough personal protective equipment (PPE) for their personal safety to acting as stand-in family members for dying patients and having to sacrifice time with their own families for fear of contagion, healthcare workers continue to bear the brunt of this ongoing crisis — and they will feel the after-effects as well.
The nursing landscape has forever been altered by the pandemic, but it was tricky even before COVID hit. An ongoing shortage of nurses, LPNs and CNAs across the country has put healthcare facilities in competition for limited staffing resources, while the burnout level of existing nurses compounds the issue. In May 2019, the World Health Organization (WHO) officially recognized workplace burnout — defined as chronic workplace stress that has not been successfully managed — in the 11th edition of its International Classification of Diseases (ICD-11). A 2017 survey conducted by Kronos found that 63% of registered nurses employed in hospitals have experienced burnout. Newer numbers are also telling: An April survey of 3,500 nurses conducted by Nursing Times shows that almost all nursing staff are feeling more stressed and anxious than usual, with a third describing the state of their mental health as “bad.” And a May 2020 NurseFly survey found greater than 50% of respondents (more than 1,380 nurses) are dissatisfied with the level of resources and training from hospitals battling the COVID-19 crisis.
In order for hospital and post-acute inpatient facilities to move forward when the pandemic finally wanes, it is essential that operators take what has been learned during the crisis and decipher what can be — and should be — adopted going forward. The ongoing challenge for owners in the post-COVID landscape will be to keep up effective patient care while maintaining balanced and healthy staffing levels without impacting costs in a manner that impinges profitability. The COVID crisis has brought home to patients and their families the importance of being able to trust their healthcare providers and the frontline employees offering their care. Thus, maintaining a trusted, experienced, balanced, and compassionate nursing staff must now be one of the most important goals for facility operators.
Key Takeaways for Moving Forward
A few strategies have emerged as essential for achieving those staffing goals:
First and foremost is the need for preparedness — during the remaining fight against COVID, and as a best practice thereafter. Ample preparation takes on several forms for healthcare facilities: ensuring that staff have effective processes for securing specialized equipment and PPE; are ready to handle potential staffing shortages among nurses and other healthcare practitioners in the case of a second wave of the virus or other unforeseen events; have in place regular “fire drills” to practice processes and strategies for handling outbreaks; and maintain a flexible and creative approach to staff composition and duties.
One facility that effectively dealt with the pandemic did so in part because it dealt with a major flu outbreak shortly before the coronavirus hit and their preparation and response put them in a better position to handle the ensuing COVID pandemic effectively. They had ordered sufficient PPE for the flu response so knew exactly where to go to get more PPE for the fight against the virus, and their hands-on training on what to do with an influx of very ill patients allowed them to have in place a full COVID response plan within two days.
The importance of training and communication in the quest for preparedness cannot be overstated. Facilities must ensure their nursing staffs have more than a handbook and a theory of how to prepare — clear scenarios and actual practice on what to do in these emergency situations is key. In addition, training cannot be limited to senior staff or managers; it must be practiced amongst all staff, and its importance must be communicated directly from the most senior person down to all levels of employees.
Effective communication is also vital for the overall staff wellbeing that is so crucial to cultivate as facilities plan for when they are able to move out of the pandemic phase. Communication that touches on recognition is very valuable as nurses and other healthcare workers struggle to carry on amidst burnout from their heavy workload. After months of working in a high-stakes, high-pressure environment, praise, appreciation, and honest performance feedback from the highest levels of the organization will go a long way with the clinical staff. Organizations whose owners and/or senior leaders show up often (either physically or virtually) and communicate in a transparent, personal, and heartfelt manner are far more likely to maintain staff with a high morale.
Creative staffing approaches are also key for healthcare facilities seeking to move forward in a positive direction. The ongoing nursing shortage is being compounded by the fact that COVID restrictions have limited the hands-on learning and training opportunities for younger nurses. This has a dual effect: it increases the burden on the existing nursing staff, and it means employers may have to pay a premium to keep or hire experienced nursing employees. High demand has yielded high competition, making proper staffing more challenging and more expensive — in some areas, facilities were offering rates as high as $125 per hour for nurses at the peak of the crisis.
While nursing staffing agencies can help with the challenge of finding nursing talent, the agency cost is often prohibitive for facilities on a tighter budget. Offering nurses and CNAs a more flexible schedule as well as bonuses for unusual effort can often go a long way to keeping them satisfied in their positions. One creative solution being used to ensure lower-level positions do not go unfilled is to make an offer on the spot — pursuant to the applicants’ credentials and other important details checking out afterward — at the initial interview. Because these lower-skilled and lower-paid positions tend to engender lower commitment levels and high turnover rates, the tactical approach of telling them right away that they are hired can be effective in securing their employment.
Virtual hiring is also emerging as a potential creative approach for operators when it comes to hiring administrative staff and senior on-site positions, such as assistant director of nursing, MDS coordinator, or marketing director. Virtual hiring through online platforms can help owners keep hiring costs down, avoid the virus-exposure risk of in-person interviews, and increase the speed of the hiring process.
Flexibility is another asset that will be crucial for healthcare facilities that wish to thrive once we land in the new normal. The ability for organizations to adapt to new processes and procedures, change staffing setups and roles as needed, and pivot quickly in the case of new waves of infection hinges on flexibility. Cultivating that flexibility among staff is again the responsibility of owners and senior managers, and it must be imbued through all levels of the organization.
Many hospitals and post-acute inpatient facilities demonstrated staffing flexibility in the face of COVID, moving nurses and other clinicians from duties that were less essential into key roles on the frontlines. With non-essential surgeries halted and outpatient services suspended, physicians shifted gears — from surgeons who helped prone patients on ventilators to office-based internists who served as hospitalists. Some facilities trained medical assistants to work as respiratory technicians, while many nurses stepped up to work in critical care, or altered their shifts, working nights instead of days or increasing from 8-hour shifts to 12-hour rotations.
This fluidity may be challenging to sustain once we are in a post-COVID environment, but the experience and willingness of staff to embrace this flexibility is something healthcare facilities would do well to applaud and maintain.
Ensuring high standards of cleanliness has always been an important focus but will become even more of a make-or-break factor as families’ heightened awareness of the crucial need for sanitized spaces may influence their decisions when choosing healthcare facilities. The value of the maintenance staff has never been higher for facility owners, and ensuring an effective — and economic — approach to environmental services is key. As appropriate, shifting duties to the maintenance staff allows the nursing staff to spend more time directly on patient care.
Some facilities are embracing a new approach of outsourcing maintenance duties, albeit with cautions in place to limit risk of virus transmission. Contracting with a specific company and putting in place an employment-type agreement with the specific person who will be performing the work are best practices to ensure health and safety. It’s also a potentially expensive option, so operators need to ensure that it makes sense for the bottom line.
Ultimately, lessons learned from being on the frontlines of the battle against COVID-19 may pave the way for improved processes in all areas of hospital and post-acute inpatient facilities’ staffing strategies. Continued vigilance in the fight against COVID and recovering from the financial, emotional, and personal toll of the pandemic will still dominate the immediate future agenda for operators of these facilities. But as we look ahead to our new normal, there are many opportunities for owners to put in place effective staffing changes that will allow them to operate in a safe, effective, and financially savvy manner while providing the very best care to their patients.
Claudia Gourdon is a Senior Vice President, Senior Relationship Manager with People’s United Bank Healthcare Financial Services. Ms. Gourdon has provided secured and unsecured financing to healthcare providers and has particular experience financing acute care hospitals, skilled nursing facilities, assisted living facilities, and behavioral facilities. She is active in HFMA and Leading Age.