Nursing Shortage and the Impact of COVID-19

Nurses have repeatedly demonstrated that they are the backbone of the healthcare system. Without nurses, the hospital will not be able to provide 24/7 care. The COVID 19 pandemic has created significant stress in many institutions throughout the world for nursing personnel. Nurses on the front lines manage these critically ill patients.  The nurses face a substantial risk to their health and safety.

Nevertheless, despite the dangers and risks, many nurses continue to serve those in need. The question becomes, as the COVID crisis continues, will the existing nursing workforce be able to continue to manage these acutely ill individuals? Burnout and stress, while well documented within nursing has been exacerbated with the COVID 19 patients. As the pandemic begins to subside in some parts of the world, will the nursing workforce simply regroup and prepare for the next onslaught of the pandemic? Alternatively, will many simply move to other types of nursing positions where they face less risk to their health?

In 2019, hospitals across the nation participated in the ANSI National Healthcare Retention and RN Staffing Survey. Respondents to the survey had indicated a turnover rate reduction goal of 3.3%. While there was a slight decrease in the turnover rate, it still stands at 17.8%. Now with the impact of COVID 19, it is anticipated the retention rate, particularly for new graduates, will markedly decrease. The certified nursing assistants who are critical to supporting patient care has a turnover rate of 26.5%. The rate will most likely also increase.

The World Health Organization estimates there is a need for at least six million nurses worldwide. The question becomes how this workforce can be educated and then deployed appropriately to provide the needed services to patients. The current COVID crisis has focused on nursing care primarily on managing and assisting these individuals. However, as patients with chronic health conditions develop acute exacerbations plus the need for surgical interventions and hospitalizations, grow nurses will also be needed to care for these individuals.

According to the Employment Projections 2016-2026  of the Bureau of Labor Statistics, Registered Nursing (RN) is ranked among the top occupations in terms of employment growth through 2026. It is expected that the RN workforce will grow from 2,9 million in 2016 to 34 million in 2026, an increase of 438,100, or 15%. The Bureau is also forecasting the need for an additional 203,700 new RNs to fill newly created vacancies and replace retired nurses each year through 2026. One might question if the forecasting is accurate.

Current models of forecasting nursing workforce needs are inconsistent, and given the nature of forecasting often is unreliable. COVID 19 was not anticipated when forecasting models were developed. The forecasting models did not anticipate that many nurses will retire because of their experience in working with patients infected with COVID 19. It is anticipated that baby boomers if they have not already retired, will do so. Generation X and millenniums most likely will stay in the workforce. However, it may depend on their experience managing COVID 19 patients. Given the high death rate from nurses infected by the patients because the lack of personal protective equipment may impact nurse’s willingness to practice in acute care settings.

Nursing schools, at least in the United States, are not able to expand clinical sites in part because of the educational model used. The educational model, with some modifications, is utilized worldwide. There are limitations to the acute care practice model used by educational institutions.  How are they going to be able to educate enough nurses to meet the need for six million more nurses using an outdated model? A model-based primarily on practicing in hospital settings.

New and innovative community-based curriculums combined, including the use of human simulation models, are urgently needed. Competency-based education that integrates a comprehensive educational experience designed to educate nurses for the 21^st century must be created and implemented. No longer can we rely on a predefined mandated clinical hours educational model. These curriculum standards rely heavily on state boards of nursing regulations regarding the number of clinical hours. Boards are prescriptive, often including the type of learning experiences students are expected to achieve. Most of these models are developed primarily from the job analysis of nurses working in an acute care environment. As the number of beds in hospitals decreases, patients hospitalized will be more acute. The nursing educational models need to be adjusted. Future nursing will be primarily community-based, caring for individuals in a wide variety of settings, and addressing many health disparity issues. Perhaps lessons learned from state boards of nursing, allowing other models of learning besides a defined number of clinical hours because of the COVID crisis will result in evidence-based changes. Given the foreseeable need for nurses, particularly in low- and middle-income countries, the need for change is urgent.

Using social media to impact health policy

Engaging in health policy—easier said than done, right? But amid this pandemic, the need for nurses to influence public health policy has never been more urgent. The reports of staff caring for coronavirus patients without adequate personal protection equipment (PPE) is, at its very core, frightening beyond measure. We see and hear their cries for help, but are they being heard? I'm left wondering, could government leaders continue to ignore the calls for change if all nurses and healthcare providers, along with their family and friends, advocated together? It can be done—and has been done—simply utilizing something most of us have direct, easy, and free access to social media. We have a real opportunity, right here and now, for nurses from a grassroots perspective to engage the public and stakeholders in a conversation about health policy needs.

Few people would fail to recognize the incredible social activism created by #MeToo, which uncovered shared stories of sexual harassment. Closer to our healthcare home, however, the viral 2014 #IceBucketChallenge aimed to raise essential funding for the Amyotrophic Lateral Sclerosis (ALS) Foundation. It is likely the most recognizable example of healthcare hashtag activism, where participants dumped a bucket of ice water over their heads in a communal effort to raise awareness about ALS.  When researchers were unable to secure the US $1 million they needed for an innovative project from the US government, the hashtag was their "Plan B." Today, it is credited with engaging over 17 million people, who uploaded over 10 billion videos. These videos were then viewed by over 440 million people internationally, with donations exceeding US $220 million. An extraordinary outcome that monumentally dwarfed their original ask of US $1 million. And that success is directly attributable to their well-heard voice via social media. Those researchers credit new gene discoveries, new stem-cell models, and a better understanding of proteins involved in the fatal disease to the viral social media campaign. Could a similar strategy be useful to advocate for PPE and other resources nurses need to stay safe?

With social media, nurses can bypass the bureaucracies of hierarchy and put into the public forum what they stand for, their values, and their message as it pertains to their renewed capacity as a health experts. As we build an audience, armed with authority as an expert and the trust that comes with being nurses, we are well-positioned to be influencers.

It is not without its risks, though. Anecdotal stories are the enemy of evidence-based practice. Privacy and confidentiality risks exist. Conflict may occur when non-verbal communication is misunderstood. Oversharing is possible. All of these give rise to the potential for unprofessional conduct.

But none of these risks are unmanageable for the professional nurse who maintains devout commitment and cognizance to their licensing body's regulations and ANA Code of Ethics as well as principles of evidence-based practice. And I'd argue, this is nowhere near as risky as caring for patients without the proper protective gear.

All that said, here are some guidelines I can offer:

1.      Make sure the intent of your message is clear and consistent.

2.      State who you are and where you are from. (Do not give your employer's name unless you have permission to do so.)

3.      Include a brief synopsis of your qualifications as a nurse expert.

4.      Explain what you wish to discuss an issue, such as PPE.

5.      Let others know why they should support or not support your issue.

Situational knowledge of the nursing experience should not be underestimated, so offering your targeted audience a patient example is what nurses can uniquely provide. Obviously, being aware of the importance of de-identifying for HIPAA compliance is essential, yet this expert advice can be enormously persuasive.

Ged Kearney, who once led clinical nursing education in a large Australian health service, successfully made the transition from nurse to a politician. Now an Australian Member of Parliament, she reflects, "I look back on my career, and I have always been an advocate; as a nurse, I advocated for patients, in the union for our membership and the health system" (Dragon, 2019). Kearny exemplifies the internal struggle nurses have where the dilemma of the health system has directly impacted how a nurse can deliver care yet have a limited opportunity to participate in the public debate. That lack of participation belies an ethical duty of concern that the nursing voice has in scrutinizing reform, regulatory changes, care coordination, and health information technology that directly impacts our ability to deliver safe and optimal patient outcomes. As Kearney said, "You have to speak up. Sometimes it is challenging, sometimes it is tough. As a nurse, I would walk into a room of physicians and health administrators, and I would think my voice was not that important. Now I look back and know that was not true. As a nurse, you develop an excellent ability to assess a situation, and I do that now. I think nurses are excellent listeners, and they can see the hidden messages" (Dragon, 2019, p. 33).

Source: Published in Sigma Theta Tau, Reflections. 2020

Addressing Healthcare Cost - Prescription Medications

In the United States, the cost of prescription drugs is one of the highest in the world. Several factors are contributing to the high cost of medications. Part of the issue is the restricted importing of medications from Canada, Europe, and other countries in which many of the drugs are manufactured. In Switzerland and other European countries, the respective agencies responsible for prescription drugs negotiates directly with the manufacturer. The negotiation centers around the cost-benefit analysis of the medication and if it should be in its formulary. The Ministry of Health spends a considerable amount of time researching which new drugs should be included in their agreement. In the United States, the Food and Drug Administration does not regulate other than the safety approvals of the introduction of medications into the healthcare system. The pharmaceutical agencies can charge whatever fees they decide. In many cases, individuals end up paying significant copayments to have access to the medications.

In part, the US pharmaceutical industry has lobbied Congress extensively to prohibit any significant changes in implementation laws. Also, the Medicare Modernization Act does not allow Congress to negotiate prices of medication. Unlike the Veterans Administration and the Department of Defense can negotiate directly with the pharmaceutical companies regarding the costs of their products. Besides, these agencies have a defined formulary which restricts the medications available to enrollees. These reports can be modified based on clinical need.

The significant profit margins particularly from Medicare beneficiaries by the pharmaceutical companies combined with their aggressive lobbying campaign will continue. There is no foreseeable end to their price gouging.  Taxpayers are continuing to pay higher prices then one should.

A related challenge is the ability of pharmaceutical companies to market directly to consumers. Other than the disclosure required by the FDA the direct marketing is thought to have a significant impact on many consumers' decisions. Of course, the drugs marketed are typically newer and have a higher price. There is a discussion that the US should ban direct to consumer prescription drug marketing.

Elijah E. Cummings Lower Drug Costs Now Acpassed in House in the fall of 2019 could save more than $345 billion in federal spending over the next seven years. Per the Congressional Budget Office, the out of pockets costs could be reduced by $158 billion over the decade. Specifically, this bill requires the Health and Human Services Sectary to negotiate rates directly with drug makers on as many as 250 prescription drugs that Medicare spends the most on. The Republican-controlled Senate has blocked movement on the bill. In the meantime, taxpayers and consumers continue to pay unreasonable prices for prescriptions.

In an article appearing in the New York Times, The American Way of Paying for Drugs Isn't Working a new poll from the Kaiser Family Foundation, reveals at least 85 percent of Americans — including a majority of both Democrats and Republicans — want the government to negotiate directly with drug makers and for the results of those negotiations to apply to private insurance as well as to Medicare. Seventy-two percent want drug makers who refuse to participate in such negotiations to face financial penalties, as they would under the proposed bill.

Support for the same ideas shrank when respondents were told that research and development would be imperiled because of these changes. The reluctance is not surprising, given the fear-mongering by the pharmaceutical industry and its supporters in Congress. However, Americans are increasingly desperate for affordable medicines. Given the system they have now, change may soon become the far less frightening option.