Nursing Retention
In the field of nursing we often face heavy workloads, mentally exhausting, physically exhausting, long hours, high stress, and working short staffed on a frequent basis. Now add a national pandemic to intensify the highly stressful occupation in the last 3 years and one can see how nursing retention is an even bigger problem. Nursing retention focuses on preventing turnover and keeping nurses in the field (Tang & Hudson, 2019). Nursing burnout and shortage are two of the biggest factors that lead to nursing retention problems. One factor to be considered in retaining nurses is that the profession and organizational leaders place emphasis on employee well-being. Employee well-being can be broken down in five areas: Purpose, financial, social, physical, and community well-being (Jacobs et al., 2018). I’ve recently started a new job working for the federal government at a VA hospital, this has been a big change from the private sector hospital I worked at for 16 years. The private sector hospital faced major issues with nurse retention. Nurses who had worked there for years such as myself were leaving due to working stressful jobs with inadequate staffing, poor benefits, lower pay than other hospitals or healthcare sectors, and generally not feeling valued. Now, I’m working in a federal employment sector where the pay is the well above average, benefits are superb, respect for staff is required, workload is divided fairly in a manor relevant to your level of education, and you are paid based on your years of experience. With all of those perks to working a federal job, there is still a big problem with nurse retention at the VA.
Social Determinants
One common social determinant that leads to nurses wanting to leave the profession is the mental and physical strain on a nurse. COVID-19 increased the physical and mental demand of the nursing profession. In an article written by Butler & Johnson (2020), four social determinants were narrowed down to: Family concerns (childcare, moving, non-job illness, and others); Economic (pay and benefits); Stress (job stress, job illness, other job dissatisfaction, nurse job dissatisfaction, and lay-off concerns); and Other (travel, another occupation, and school). After COVID hit in early 2020, all of these social determinants were even more affected and caused an even higher rate of nursing job turnover and a mass exodus in the nursing profession. A survey released by Elsevier in 2022 reveals a prediction that 75% of healthcare workers will leave the healthcare profession by 2025 (Bruisie, 2022). Nurses make up the biggest population of healthcare workers so if this prediction comes true, healthcare will be in for another transformation and crisis.
My Workplace Retention Strategies
The VA has done some restructuring to improve nurse retention. The organization has adapted to the Theory of Complex Adaptive Systems which recognizes the need for an organization to adapt to change which leads to new and creative solutions to problems within the system (Broome & Marshall, 2021). The VA recently owned up to the fact that they were one of the lowest paying organizations in healthcare, nurses received a huge raise in salary as high as 24%. Registered nurses are given an $8000 sign on bonus to be distributed in 4 payments over a year. After 1 year of employment, the VA offers the Education Debt Reduction Program (EDRP) which pays up to $200,000 of student loans. The benefits such as medical, dental, and vision insurances are offered at great rates and provide excellent coverage with a variety of choices. Retirement is one of the best on the market matching 5% of employee contribution and paying $.50 on the dollar after 5%. Paid time for 13 federal holidays as well as earning 12 hours of leave time every 2 weeks. Last but not least, nurses get 5 weeks of paid vacation from the start of their career at the VA. Just to show how good this is to me, my former employer I gave 16 years of my career to matched 3% max on retirement, after 16 years working I was up to 4 weeks vacation I had to pay for using my PTO which I also had to use to cover sick time and days we were closed for holidays. Progress is being maJade but the VA along with all other healthcare sectors have a long way to go and must stay current with benefit and pay incentives to improve nurse retention rates. Along with pay and benefits, employee well-being must be given high regard as well to promote a healthy work environment.
One huge healthcare issue that we are all facing today is nursing burnout and shortages. There has been an increase in registered nurses and advanced practice nurses over the years due to the aging population and need for healthcare however, due to the increase in demand for healthcare, this can cause turnover and burnout in the healthcare providers (Broome & Marshall, 2021). One study has shown that physicians and nurse practitioners working together to meet the increased demand of patient care is aimed at preventing burnout and improving access to and quality of care (Norful, de Jacq, & Carlino, 2018). The supply of physicians over the years has decreased which has not helped the demand of healthcare services needed. The longer medical education needed for physicians contributes to the shorter supply which is where advanced practice nurses can alleviate this constraint since their training is shorter (Auerbach, Staiger, & Buerhaus, 2018).
The shortages and staff burnout has caused many issues within healthcare. Just in the emergency department that I work for, the shortage of nurses we experience is causing us work fatigue and burnout. This has a direct impact on nurse retention. Nurses are leaving the high stress setting of the emergency department to work for a lower stress job. There are times I am taking care of intensive care patients plus emergency care, such as cardiac arrests. This causes nurses to question the care they provide and if is high quality because of the needs of these patients. It also makes them question if their license is at risk.
Social determinants of health such as underserved areas is impacted by the shortage of nurses and providers. A culturally diverse nursing staff can help with more competent care of minorities. However, this cannot be accomplished if there is a shortage of staff. We currently have four nurses on staff in the community emergency department that I work for who are Spanish. The Spanish population in this particular area is high so it is important to have staff that know the culture and language for better patient care. Patients with this ethnic background would be more trusting of healthcare staff that have this culture knowledge and experience (Broome & Marshall, 2021).
The healthcare system I work for is attempting to respond to the shortage to end nursing burnout and turnover. They have hired a nursing recruitment agency that is offering sign-on bonuses in order to attract more nurses. They also have offered overtime bonuses to help with the day-to-day operations and have travel nurses working as well. When it comes to the shortage of providers like physicians and advanced practice nurses, they have been using locum tenens (temporary providers) and float providers within the healthcare system. The float providers bounce from hospital to hospital within the healthcare system. Although there are a couple ways they are trying to assist with the shortage to avoid burnout in staff, it seems these measures aren’t really helping. Some staff work the overtime to help however, we are still losing nurses because they are tired and want a lower stress job.
Lack of Mental Health Resources
Lack of access to mental health resources is a problem that is getting worse. The Covid-19 pandemic put a significant strain on an already strained healthcare system, making providers and organizations do more with less, some even having to close their doors permanently. In April 2020, of the surveyed community mental health facilities, two-thirds stated that due to the current financial climate, they believed they could only keep operating for a maximum of three months (Majlessi, 2020). Organizations had to make significant staff cuts, decreasing their revenue while trying to curtail overhead costs. While it did help decrease the costs associated with daily operations, it also decreased the organization’s capability to service more patients and therefore bring in more income.
The pandemic did bring some innovation to providing healthcare for the medical community. Telehealth was more widely accessible, allowing for expanded services in rural and urban areas. Currently, 150 million Americans live in a federally designated mental health provider shortage area (Weiner, 2022). This problem has been a persistent issue even before the pandemic. Telehealth services can cover these areas, but that is not always an accessible or appropriate solution for all patients.
In Iowa, a state ranked dead last in the country in access to mental health, only two beds are available for every 100,000 people (Carpenter, 2023). This creates backlogs in ER and outlying facilities holding patients waiting for an inpatient bed. Access is impacted by social determinants of race, ability to pay, insurance, and location.
Workplace Response
The unit I currently work in came about as a response to many mental health patients waiting in the Emergency Room (ER) for days, waiting for a bed. This decreased our ER’s ability to see and treat patients as rooms were full of holding patients. As a result, one of our nurse leaders created a crisis observation unit to hold medically cleared psychiatric patients awaiting an inpatient bed. This unit is for adults only, with the possibility of opening a pediatric hold unit. This unit is staffed by psychiatric nurses that can adequately meet these patients’ needs. It also provides the patients more freedom- they have their own room and bathroom, and have access to a common room and complimentary therapy, if desired, rather than waiting in one room for however long it takes to find placement for them. Our psychiatric providers oversee these patients and coordinate care with outside facilities. We have a liaison on-site during the week from a local inpatient hospital to assist with placement in their facility and a telehealth service over the weekend that assists with placement. This unit is open to five beds currently, with plans to expand to twelve beds.
Nurse Practitioner Autonomy
One major healthcare issue we are facing today is a provider shortage. With an ever-aging population, many estimates show that in order to meet the demand for primary care providers there will need to be an additional 52,00 primary care physicians by 2025 (Poghosyan et al., 2018). Primary care provider shortages have caused many states to remove the need for practice agreements between NPs and physicians. One such state is NY after passing the Nurse Practitioner Modernization Act which would enable NPs to practice without written agreements after 3,600 hours of experience (Poghosyan et al., 2018). Getting society, organizations, and physicians to realize that NPs can be valuable independent providers, especially in primary care, is a national healthcare issue. Likewise, another possible model to decrease strain on primary care is the co-management of patients between NPs and physicians (Norful et al., 2018). One study showed that this model can alleviate burnout, improve patient quality, and decrease individual workload (Norful et al., 2018).
Current Workplace
Currently, I work in a correctional setting that hires FNPs, Adult NPs, and PAs as mid-level providers. Working in a correctional setting we are constantly short-staffed in the medical department including providers and nurses. In my place of work, mid-level providers can treat and provide autonomous care however require a physician to cosign on some prescriptions such as opiates and some psychiatric medications. Nurse practitioners can also perform simple bedside procedures such as I&Ds, suturing, stapling, and toenail removals. Recently, the agency I work for also started to hire PMHNPs at medical centers due to the psychiatric provider shortage. In order to attempt to recruit and retain more providers, the agency I work for has also offered generous 25% recruitment and retention bonuses along with paid moves. While there is room for improvement, the agency I work for has gone through great strides to improve mid-level provider autonomy.
Conclusion
A study was performed at the VA comparing patient outcomes between patients assigned to an NP versus M.D. in various clinical settings (Liu et al., 2020). The study found that patients assigned to NPs were less likely to use primary care and specialty care services and incurred fewer hospitalizations (Liu et al., 2020). Likewise, the clinical outcomes, diagnostic workups, and costs were not a significant difference between NPs and MDs (Liu et al., 2020). This shows that NPs can and should be trusted to provide patient care independently since they provide the same or better outcomes compared to MDs in some circumstances. While some states have allowed NPs to practice autonomously, others still require physician collaboration which puts unnecessary strain on an already strained healthcare system.
Workplace violence can occur physically, sexually, mentally, and through neglect. Violence can include beatings, shootings, rapes, threats, intimidation, harassment, and being cursed at/shouted at (Baker and Alshdefat 2020). Although workplace violence in healthcare is a largely arising issue, nurses working in psychiatric facilities are 20 times more likely to be assaulted than any other field (Baker and Alshdefat 2020). It’s reported that approximately 68/1000 psychiatric nurses are assaulted by patients whereas approximately 21/1000 nurses in other fields report workplace violence (Baker and Alshdefat 2020).
Long term complications of being a victim of workplace violence includes anxiety, post-traumatic stress disorder (PTSD), decreased productivity, increased burnout, death, and fear of returning to career but the continuous exposure to violence tends to lead nurses to feel that it’s just an accepted part of their job (Baker and Alshdefat 2020). Short staffing, lack of security, inadequate training, and uncoordinated treatment interventions play a huge role in increasing the risk of workplace violence occurring (Baker and Alshdefat 2020).
Social determinates of workplace violence include patients suffering with untreated mental health disorders, active substance abuse issues, inability to cope with situational crises, access to weapons (such a scissors or metal cans), and their own PTSD from history of violence. Worker risk factors include age, years of experience, gender (women are most likely affected), and absence of training in violent situations (Gillespie et al.).
A couple of months ago I left my job of nearly 3 years at a psychiatric hospital. I loved my job and what I did but the lack of support from management and lack of training for new hires was being physically dangerous. Within a one-year span I was held at gunpoint in the parking lot, spit on, punched, had a printer and desk chair thrown at me, almost received stitches from being hit and scratched, and was kicked in the face due to a new employee not being educated on proper hold techniques. Our facility had no security and an outdated security camera system that never worked, and they had no intentions on changing any of the flaws. During our handle with care training for new hires to learn how to safely do holds, seclusion, and restraints since covid the training was verbal and not hands on. It’s important to understand the steps of things you’re doing to prevent injury to staff and patients before a situation arises.
One of the most in-demand professions nowadays is registered nursing. They offer care in every area associated with health care, including hospitals, doctor’s offices, outpatient care facilities, skilled nursing facilities, behavioral health settings, the home, schools, universities, jails, and workplaces owned and operated by private parties. In addition to being essential patient care providers, nurses play a significant part in addressing health outcomes disparities and enhancing the general well-being of the population (Zhavoronkova et al., 2022).
Nurses have started leaving the healthcare setting in droves, especially since the increased demands placed on them during the pandemic. Nurses have to take on increased patient loads which can adversely affect the rest of the patients they are caring for. These high staffing ratios are a surefire prescription for failure, as anyone who has worked at the bedside can attest. If nurses are given too many patients, they cannot give the best care. Some patients might not get all the required components of evidence-based care, and some requirements might need to be met. It is a system failure, not the nurse’s responsibility that this circumstance exists (Bourgault, 2022).
Some of the social determinants affecting our nursing shortage and burn out are the aging nursing workforce population, increased health demands due to an older population requiring increased care, higher hospital censuses, and greater acuity of the patients. Another major factor is the lack of nursing students that are graduating. Several nursing programs in the United States struggle to build facilities to accommodate qualified nursing candidates. Over 90,000 suitable undergraduate and graduate nursing students were turned away from schools in 2021, according to the AACN’s report 2021-2022 Enrollment and Graduations in Bachelor and Graduate Programs in Nursing. These rejections were due to a need for clinical education sites, classroom space restrictions, and staff (Tamata & Mohammadnezhad, 2022).
Academic Progression in Nursing supported initiatives on two fronts: initiatives that remove barriers that prevent nursing students from earning their BSN, such as support for collaborations between universities and community colleges to enable smooth progression from the associate’s degree (AD) to the baccalaureate; and employment-focused collaborations between schools and healthcare facilities that give students practical experience, encourage greater use of the BSN and create employment opportunities (Gerardi et al., 2018, p. 43).
I currently work in Hospice. We do not have a standard patient-to-nurse ratio. As a whole corporation, they have seen the increased demands on nursing staff and have allotted more nurses to be hired. However, appropriate candidates are hard to find, and few apply. A way our main branch is handling the nursing shortage that we are going through right now is that our director of operations has started to assist with patient admissions and on-call schedules. Our office is working together and being transparent about our difficulties and burnout. This was discussed in Pittman’s article. It was noted how important this was to establish this change (Pittman & Scully-Russ, 2016). Our director of operations is a great leader and checks with the staff daily to see how she can help.
Another significant concern that our director has noticed is taking on new patients that it would take longer than an hour for a nurse to get to. She is looking at how far the patient lives from our main office, and if it is not feasible to provide the proper care to the patient, we send that patient to a different hospice company and ensure they can provide the adequate care required for this patient. Our director is putting her staff first and not the financial bottom line.
In conclusion, the nursing shortage is not a new issue. However, it is now more pronounced as nurses put boundaries into place and expect more from their employers. As healthcare evolves and demands increase, nurses will continue to speak up and advocate for themselves and their patients. The best way to positively affect the nursing shortage and burnout is to listen to what the nurses and health care professionals are saying. There is not one fix all for this solution. It is gonna have to be tackled company by company throughout the world.
Despite nursing shortages being an issue for many decades in many countries, the global health crisis has impacted the profession significantly. Since the Pandemic, nurses have been exacerbated by its impact. Many nurses were left suffering from mental and psychological exhaustion, frustration, and loss of passion for the love of patient care; these symptoms left many nurses that were highly qualified, skilled, and with years of experience in the profession exiting their roles to venture into different opportunities that were less demanding and stressful. Haines (2022) reported that the proportion of nurses in the profession that are between the ages of 25 and 34 is the largest, but between May 2020 and May 2021, their numbers plummeted by 5.2%, while the second largest proportion of nurses in the age group between 35 and 44 plunged by an even greater 7.4%. Also, the aging population and the need for healthcare have increased the demand for registered and advanced practice nurses over the years; however, the increased demand for healthcare has led to caregiver burnout and turnover (Broome & Marshall, 2021). While many may have theorized that the current problem lies with the number of staff enrolled in the profession being on the frontline, it can be quickly concluded that the actual problem is simply the number of qualified nurses that no longer have the zeal and passion for providing patient care.
I work in the ICU, where my current state and concern for my license are at an all-time high. The impact of nurse shortages has seen nurses practicing unsafely as the nurse-to-patient ratio in a critical setting is unsafe and has caused poor patient outcomes and increased patient stay due to poor nursing practices. Due to the nurse shortages, nurses having to work longer hours further distort their nursing judgment, leading to an increased medication error, increased workplace hostility among staff, and an unsafe working environment. Decreased patient satisfaction is also a significant concern in my work setting because patients have to wait longer for services, e.g., pain medication, thus increasing their suffering. The healthcare setting I am affiliated with was once a magnet institution, which meant the level of nursing services provided was second to none; however, since the satisfaction rate has plummeted drastically due to nursing staff shortages, they no longer hold that status. Hospital-acquired infection such as Catheters-associated Urinary Tract Infection (CAUTI) has also increased due to poor management, e.g., Foley cares every 8hrs not being done, Central line-associated Bloodstream Infection (CLABSI) and Ventilator-associated Pneumonia (VAP) is also on the rise because of nurse shortages.
According to Haddad et al., 2022, nursing continues to face shortages due to a lack of potential educators, high turnover, and inequitable workforce distribution. Some of the social determinants that have been impacting the nursing shortages are burnout; this is so due to nurses having to work longer working hours to help cushion staff shortages in some facilities, e.g., in some institution, after working a 12hr shift, nurses are mandated to work an extra 4hrs because the facility is short-staffed. Technological advancement has seen people live longer due to new and improved ways to treat many illnesses. Haddad et al. (2022) postulated that as the population ages, the need for health services increases, and currently, the United States has the highest number of Americans over the age of 65 than any other time in history, with statistics indicating that for 2029, the last of the baby boomer generation will reach retirement age, resulting in a 73% increase in Americans 65 years of age and older, 41 million in 2011 compared to 71 million in 2019. As the baby boom generation reaches retirement age, the population is aging, resulting in a greater need for health services. Another social determinant that has affected nurse shortages is violence in healthcare. Verbal, physical, and psychological abuse are some of the hostility nurses face daily at the bedside leading to many nurses resigning as caregivers. According to the World Health Organization (WHO), “between 8 and 38% of nurses suffer from healthcare violence at some point in their career” (Kafle et al., 2022). Because of how common violence and abuse against nurses have become, it has not only led nurses to exit their role in the profession, but its impact has decreased productivity and patient outcomes.
Dr. Brenda Freshman has alluded to the notion that to address future challenges in healthcare, the most crucial thing leaders can do is develop cultural competency, the ability to take multiple perspectives, and a greater understanding of the whole system of the organization (Walden University, 2015). To help alleviate this issue, my healthcare facility has tried to hire outside recruiters with attractive and competitive pay packages that attract travel nurses to sign a contract for 13-26 weeks and work a 48hr work week. The organization has also hosted job fairs to lure in recent graduates and nurses interested in working for an attractive compensation package with an enormous sign-on bonus for up to three years. Further measures taken by the facility to combat nurse shortages include the implementation of up staffing and mandatory on-calls. To retain their current staff, they have been considering retention bonuses that will help to prevent their highly trained and qualified nurses from resigning. Another effort by the organization to address nurse shortages is the impending introduction of remote nurses, who will support bedside nurses and give them greater flexibility in providing better care for all patients. Finally, more grants and scholarships are introduced for nurses to continue their education, which has seen many nurses capitalize on this opportunity to help boost their morale, which benefits the organization in the long run.
The Healthcare system has suffered immensely since covid, and the aftermath has left many healthcare workers struggling to continue their work at the bedside. The demand for healthcare services has caused more stress to nurses, and as such, despite measures implemented, nurses are still abandoning their roles for jobs that have less stress and demands.
Review of Current Healthcare Issues
Depending on who you ask, answers will vary significantly on what is thought to be the most significant issue facing healthcare today. As nurses, it is important to stay up to date on these national issues so that understanding and implementation can be translated into the workplace. The purpose of this discussion post is to select one current national healthcare issue to reflect on and to think about how it is addressed in the workplace setting.
Nursing Shortages and/or Appropriate Staffing
In America, the total number of working registered nurses is about four million (Baker, 2022). Historically, there have rarely ever been enough nurses to act as a supply for the demand of services needed. Recently, with the COVID-19 pandemic, the supply of registered nurses has decreased while the demand has significantly increased. This is due to many reasons. Some nurses have gotten ill from the pandemic and have not been able to return to work while others have chosen to retire to avoid being surrounded by COVID. Another reason includes burnout and turnover from this increased demand (Broome & Marshall, 2021). When there are not enough nurses available to be scheduled on a unit, organizations are forced to use short-term solutions to provide appropriate care. Some of these short-term solutions include the use of agencies to supply travel nurses as well as bonuses for those already on the payroll (Chervoni-Knapp, 2022). These are considered short-term solutions as they ultimately are not sustainable for organizations to be involved in for a long period of time (Chervoni-Knapp, 2022). Organizations are faced with this tough choice as the alternative of not enough nursing staff would mean that fewer patients are cared for and less money is made for the company. This could result in entire organizations having to shut down which then would lead to significantly fewer beds available for those who are sick. As you can see, there is no perfect solution for this problem and most organizations are trying their best just to get by.
Workplace Impact
I have worked at an inpatient psychiatric facility since 2019. It has been an interesting experience to work before COVID, during COVID, and now, while COVID is decreasing. Before COVID, the unit where I worked was always appropriately staffed, if not overstaffed, on each shift. I remember being canceled every so often as we consistently had more than enough nurses to care for the patients. During COVID, there seemed to never be a day that enough nurses were working. My workplace utilized travel nurses and registry agencies to maintain adequate license-to-patient ratios. A downside to this short-term solution is that for one, these nurses cost a greater amount of money than regular staff nurses do due to the demand as well as these nurses are not familiar with the unit or the company procedures and need time to learn. These downsides created an upset in the unit where I worked. Now, since COVID has been decreasing, my unit has not needed to use travel nurses or agencies to staff it appropriately. We still are not always fully staffed, but accommodations have been made. One is that the organization offers bonuses to staff to come in on their day off if the unit is short. Another is that if another unit has extra staff, they will be floated to my unit for the day to help out. This has been working enough for the past few months. I hope to see soon where the unit starts becoming adequately staffed again.
Conclusion
In conclusion, national nursing and healthcare issues are prevalent throughout America. Every nurse and organization will have an opinion on what they believe is the most significant issue. This being said, the issue of nursing shortages and struggles with appropriate staffing has been endured by most due to the COVID-19 pandemic. Overall, nurses should be educated and aware of these issues so that complete understanding and change can occur.
As many of us pursuing degrees as advanced practiced registered nurses (APRNs) know, despite receiving an expansive education to provide care to patients, the state that we choose to practice in, its laws and regulations, will affect to what capacity we are allowed to practice and utilize the skills we have learned (American Association of Nurse Practitioners, AANP, 2022). Although strides to expand scope of practice for APRNs have evolved over the years, there are still limitations. These limitations are problematic because of shortages in healthcare professionals, particularly advanced practitioners. As Poghosyan et al. (2018) discusses, for example, that more than 50,000 physicians will be needed by 2025 to meet the demand for primary care but the number of physicians are decreasing while the number of nurse practitioners (NPs) that could potentially fill these gaps are increasing. Health care disparities and inequalities are not new topics, but in this world of Covid-19, these disparities and inequalities, the social determinants affecting them, and the resulting patient outcomes have been highlighted and emphasized (Heath, 2020). Heath (2020) continues to state that health inequalities are rooted in the social determinants of health because they can limit an individual’s ability to achieve optimal health and wellness.
For this issue, the social determinant most involved in this topic is health care access and quality, specifically access to time effective and “high-quality health care services,” because limiting the nurse practitioner’s ability to practice to the full extent of their education and knowledge limits how they can be adequately used in every community to contribute to the availability of health care services to the members of those communities (U.S. Department of Health and Human Services, HHS, n.d.). Nurse practitioners can play an important role in addressing this issue not only because of the increased numbers of nurse practitioners in the workforce but also because of the nursing approach founded in holistic patient care, building a connection with patients, and practicing with compassion and empathy (Heath, 2020). Expanding nurse practitioner scope of practice regulations can allow them to work to their full potential, fill in gaps in care that physicians are unable to, and provide care to the millions in communities with limited access to primary care or other care. For example, the ten states with the most flexible nurse practitioner scope of practice laws and regulations have some of the best overall health outcomes while the ten states with the worst overall health outcomes have the strictest laws and regulations regarding nurse practitioner scope of practice (Heath, 2020). Broome and Marshall (2021) also discuss how APRNs are a resource that should be utilized fully by referencing a study in which “the addition of nurse practitioners (NPs) to an inpatient care team at a single site demonstrated enhanced revenue through gross collections and cost efficiency, reduced overall lengths of stay, and standardized practices to improve quality of care” (p. 71).
As a travel nurse, I see the workings of many different facilities and how functioning with limited staffing versus adequate staffing can affect team communication, timely patient care, and patient outcomes. The lack of more autonomous APRNs in the inpatient setting, from my experience, leads to longer wait times for patients and bedside nurses to hear from the care team about issues that arise and to participate in care team rounds that require the physician to be present. Of course, bedside nurses can call, page, or message the physician, resident, intern, or even the physician assistant if applicable but typically nurse practitioners are not utilized as a functioning, decision-making part of the team which would be valuable. For example, I have had patients complain about feeling neglected by their physician because no one was able to round with them for a day/a few days or that no one from the care team came to see them until late in the day because the physician and team of residents and physician assistants were busy with other patients and tasks. A nurse practitioner may have been helpful to fill these gaps. Also, because nursing education is grounded in a holistic approach at every level, their input may provide a different perspective to the care approach and decision-making that may improve patient-provider relations and patient outcomes. Again, as a travel nurse, I do not have much insight into organizational changes or initiatives because of the limited amount of time I spend at each facility, however, at the current facility I work at in California I can honestly say that I have not heard of any initiatives to alleviate this issue during huddles or unit meetings. I cannot recall interacting with a nurse practitioner at this facility at all. From what I have heard from staff members, this Kaiser facility does not utilize nurse practitioners at all or very rarely. This may be a consequence of California state law and/or specific Kaiser policies in this region. This facility could greatly benefit from utilizing nurse practitioners from my experience as I have had the pleasure of working with APRNs in my home state of Pennsylvania; they serve as an invaluable resource and bedside nurses and physicians alike relied on their expertise greatly. As Poghosyan et al. (2018) reports, many physicians believe that nurse practitioners are competent members of the care team that can expand the capacities of health care practices and help meet the increased demand for quality patient care.
National Healthcare Issue/Stressor – The High Cost of Health Care
Healthcare expense in the United States is among the highest in the world compared to other developed nations. The US spent 4.3 trillion dollars on healthcare in 2021, or around $12,900 per person, according to Peter G. Peterson Foundation (2023), compared to other first-world countries that only charge around half as much for healthcare per person. Healthcare expenses have risen over the past several decades relative to the size of the economy, from 5% of GDP in 1960 to 18% in 2021 (Peter G. Peterson Foundation, 2023). The rising aging population and healthcare costs are the two most significant drivers. The proportion of Americans aged 65 and older has increased considerably (Broome & Marshall, 2021). Americans over 65 spend more on healthcare than any other age group because of age-acquired illnesses. The cost of healthcare services frequently increases more quickly than the cost of other goods and services. The Consumer Price Index (CPI) for medical care has increased by 3.4 percent annually.
The introduction of cutting-edge, innovative healthcare technology that results in better but more expensive services and products; organizational waste in the insurer and provider payment systems may be brought on by the complexity of the American healthcare system; and hospital mergers may bring about a lack of competition and a monopoly that attracts high prices are a few additional potential causes for the rise in healthcare costs (Peter G. Peterson Foundation, 2023). One-fourth of people report delaying or skipping care due to cost, making costs a significant barrier to access. High healthcare costs sometimes prevent people from getting essential care or finishing their medications. They have missed doses, cut pills in half, or not finished prescriptions in the last year, with more significant percentages among those with lower incomes (Montero et al., 2022).
Impact on Work Setting
The hospital had noted a tendency in some patients who could not pay for care when they first sought medical attention and later learned they had severe illnesses due to delaying or skipping medical visits for routine checkups, therapy, or rehabilitation following surgery or a treatment, aftercare, or an inpatient stay. As a result, of the high cost of medical treatment, patients’ health deteriorated, and undiagnosed or untreated medical conditions developed worsening symptoms, necessitating additional, more expensive therapies that would only worsen the initial problem causing these patients to be admitted to the hospital (Experian Health, 2022). There are more patients with serious issues who, if appropriately managed as outpatients, may have avoided admissions to emergency room (ER) services for medication-related diseases that escalated because they missed doctor appointments. It often results in a needless ER admission, which raises medical expenses since ER treatments are generally expensive (Rakshit et al., 2023). As a result of unpaid medical bills, calls to patients to inform them about outstanding debts for at least 120 days before pursuing extreme steps have increased. Invoices are subsequently forwarded to a collection agency when all available payment alternatives have been offered to the patients and have yet to be taken advantage of have been seen. Patients with medical debt hospitalized for stress and high blood pressure are becoming more common in this hospital (Rakshit et al., 2023). Due to the high cost, it is found that some patients are thinking about switching providers and moving to a location with lower costs. When patients fail to appear for their appointments, it jeopardizes the quality of medical services. It affects resource efficiency, resulting in a loss of projected income in services, interfering with medical processes, and wasting time and resources.
Social Determinant
The effects of high healthcare costs are felt most acutely by those without insurance, those of color, and those with lower or no incomes who lack healthcare resources to obtain health insurance or pay for expensive procedures and prescription drugs. Some people claim that they cannot afford specific forms of therapy and delay or skip receiving medical care due to the cost (Montero et al., 2022). Individuals who reside in rural areas, belong to specific racial and ethnic groups, are physically disabled, or are members of specific communities are more likely to struggle financially to pay for expensive healthcare. Institutional racism and discrimination lead to disparities in social and economic opportunities and resources. The resources necessary to ensure a high quality of life, such as healthcare programs like Medicare and Medicaid, are typically inaccessible to those in disadvantaged areas. Unfulfilled social needs, environmental factors, and barriers to seeking medical care, such as high expenses, all contribute to worse health outcomes. Poverty can limit access to educational and career opportunities and widen the wealth gap, creating a vicious cycle of poverty and the inability to pay for adequate healthcare. The risk that an individual would experience poverty as an adult rises due to childhood poverty, which feeds poor generational cycles (H HS, n.d.). People without access to quality education throughout their lives are more likely to find themselves in difficult financial situations, making it more challenging to afford quality healthcare. The likelihood of finding higher-paying occupations with fewer safety dangers increases with education. More educated people ultimately have more significant financial resources to pay for and receive high-quality healthcare.
Health System Work Setting Response
Being a non-profit hospital, the healthcare system where I work provides treatment for those in need, regardless of their financial situation or state of health. No matter what medical challenges a patient may encounter, they can obtain the best care possible because of their financial support and other measures they have put in place to help pay for medical bills. The hospital’s billing office telephone number allows patients with financial difficulties to call and discuss options like a payment plan or financial aid. These services for financial support consist of fair and standardized billing and collection procedures, such as Charity Care, financial aid policies, and a standardized application procedure. Once a patient is eligible, their Charity Care programs are utilized to pay all or a portion of the hospital charge. There is also a payment arrangement with zero interest and extended payment plan choices for patients who owe medical bills to pay off their debt affordably. This hospital provides a minimum monthly payment of $25 for 36 months. This enables people with high medical costs to stay compliant with their medical care and has a positive societal impact (Parkview Health, n.d.). This hospital prevents surprise medical expenditures by providing patients with realistic pricing projections. Clear and precise estimates are provided to equip patients better to arrange their finances and make treatment decisions. The estimates are provided to patients through an easy-to-use self-service website (Parkview Health, n.d.). Despite budgetary limitations, this hospital also provides emergency care. It is one of 12 grant recipients countrywide who must get money to develop its Medication Assisted Treatment (MAT) clinic program, with aims to treat drug addiction disorders, notably opioid misuse disorder, by offering free medicine, counseling, and behavior therapy to patients who would not otherwise be able to pay for their prescription medications (Parkview Health, n.d.). Employee discount offers a variety of healthcare goods and services to its employees and beneficiaries. Also, this hospital employs social workers and medical professionals who inform patients of outside resources they might use for assistance. With case management, patients may set up Medicare and Medicaid programs. They have pharmacy discount cards available and provide information about healthcare facilities like Matthew 25 Health and Care, a gospel-inspired medical facility. They offer high-quality medical and psychiatric services free of cost to low-income, uninsured adults, bringing joy to the most vulnerable in the neighborhood by treating them with kindness and dignity despite their socioeconomic status or religious views (Matthew 25 Health and Care, n.d.).
Healthcare Issue/Stressor-Nursing Shortages and Quality of Care
Every day, nurses are expected to do their job and do it to the best of their ability. I currently work in a clinic setting, and we are adding more and more clinics. Each nurse has clinics they are specifically assigned to. But what happens when they keep adding more and more, and we only are allowed a certain number of employees? Well, I can tell you that we will have to work those clinics and care for those patients. The biggest question that comes to mind, though with that, is how thin can staff be stretched? We run into issues such as insufficient time to room patients and get a full health history appropriately. So then, what are we missing that we should be aware of. That, for example, leads to quality-of-care issues. As a patient, I know I’m not the only critical patient that day of my visit, but I know I’d like to feel like they are dedicated enough to learn and know my whole story, problems, etc., to develop a plan of care. The example listed above is only one example of how nurses are shorted and overworked many times, and in turn it lacks on the patient care end and providing quality care simply because they do not have the time.
Many reasons have caused staff shortages, but today, one can think that the COVID-19 pandemic did not help the situation. Any nurse that worked through it probably wanted to run away from it. Most healthcare entities had difficulty staffing their facilities during the pandemic, especially in rural communities. Nurses being short staffed causes increased mortality rates, length of stays and hospital readmissions, patient safety problems, errors, lack of quality of care, and wait times (Norwich University Online, 2020). The nursing field continues to experience exhaustion and burnout. The nursing turnover nationally ranges from 8.8-37% (Haddad et al., 2022).
Social Determinants
Social determinants of healthcare are the patient’s financial situation, their level of education, employment status, work and home conditions, ability to get food, age-appropriate development, social situation, and affordability and accessibility to quality of care (World Health Organization, 2018). When speaking of quality care, all the social determinants of care can be quality factors. Specifically in our clinic, financials are a bit problem, especially when it comes to getting medications that are prescribed. Thinking back to a specific example of a patient not being able to afford simple over the counter medications for a colonoscopy. We then had to send in the MiraLAX and Bisacodyl through insurance because they could not pay for them through food stamps. Many of the patients with low socio-economic status’ do not receive the preventative care they need until major health problems arise, and that is when we see them more in the clinic in one or more department. This is, in turn increases patient loads because of the many appointments that they have in the clinic or even some patients we have come in for daily or even twice daily antibiotic infusions, which we must work our other patients around. Again, going back to only so many staff nurses, being shorthanded, affecting the quality of care, and needing time to care for each patient appropriately.
Response
Our clinic setting has taken a team approach in this staffing issues. We stay central to our clinics to maintain continuum of care, a positive aspect of quality of care. We have had to learn new clinics to ensure their patient load is appropriately cared for. In our downtime, we get into the inbox and promptly respond to patient calls, refills, and results notes. Hopefully, we will also add a specific nurse that can take care of prior authorizations, med refills, result notes, patient notification, etc,. That way the rest of the nurses can focus on patient care. We also have a manager that genuinely cares about quality care and how the clinic runs. She also assists in getting PRN help when needed as well. Many aspects make up quality patient care, and just because we are short staffed and they are adding more and more clinics does not mean that we cannot provide the best care around. I would compare our approach to the core competencies of teamwork, values, responsibility, knowing our clear roles, and communicating with one another (Broome & Marshall, 2021).
National Healthcare Issue/Stressor
The national healthcare issue/stressor I have chosen is COVID-19 and personal protective equipment. Any change in a work setting comes with pushback. In healthcare, change is inevitable and learning how to cope with change while delivering effective care is necessary for healthcare professionals (Broome & Marshall, 2021). COVID-19 was a change that was unexpected and led to massive changes in a short amount of time. Hospitals and healthcare facilities were not prepared for a pandemic and PPE was in high demand. COVID-19 caused stress for healthcare workers due to lack of resources, unsafe working conditions, long working hours, stress of exposure, and PPE that was uncomfortable and hard to work with (Evcili & Demirel, 2022).
Impact on Work Setting
I currently work in a peri-op setting and before COVID we were only required to wear PPE when the patient had a known respiratory illness or if was required due to a different isolation reason such as C-Diff. Due to COVID, we now always wear masks in pre-op and PACU. When COVID was at its peak, we had to always wear N95s and protective eyewear. Our healthcare system still requires staff and patients to wear a mask. Many people have pushed back and have left to other systems in the state who do not require staff to wear masks.
Social Determinants
Social determinants that have been affected due to COVID and PPE are working conditions and medical care. COVID has made working conditions stressful for healthcare workers and being in PPE 12 plus hours a day is very uncomfortable. PPE and COVID at its peak, affected the care patients received because nurses had to learn how to reprioritize their work and provide tasks for many patients at a time. COVID-19 has led to missed nursing care and leads to longer lengths of stay for patients and higher rates of readmission (Khrais et al., 2023).
Health System Work Setting Response
COVID has affected all healthcare workers in some way. Healthcare is still recovering from it. There has been recent talk in my healthcare system that masks will not be required anymore due to pushback from patients/staff. Our organization currently does not require them in a non-clinical setting. I will be interested to read if other healthcare systems still require them in other states from all of you!
Staff Shortage in Long-Term Care Facilities
The national issue of nursing and primary care provider shortages constantly impacts work in my healthcare settings of long-term care and rehabilitation facility within the ProMedica healthcare organization. Ricketts and Fraher (2013) noted that the nursing shortages pattern resembles a sinewave prompting policy development that “stimulates rapid growth leading to surpluses” (p. 1876). Periera and Bowers (2021) confirmed that “the nursing supply between 2014 and 2030 is expected to exceed demand, with a projected surplus of 293,800 RNs by 2030” (p. 83). Despite these projections, the skilled nursing facility (SNF) where I work constantly experiences workforce shortages in nursing assistants, nurses, and primary care providers. The nurse-patient ratio of one-to-thirty instead of one-to-twenty became the new normal, inevitably resulting in diminished quality of patient care, patient dissatisfaction, and staff burnout. The continuous effort of Human Resources to hire new employees does not have much effect on adequate staffing either due to high turnover rates. According to Periera and Bowers (2021), “turnover of nurses within healthcare organizations is common, with 20% of nurses leaving their job within the first year of employment” (p. 84). Therefore, to maintain sufficient staffing and uninterrupted work of the facility, reorganizational strategies should be implemented beyond simply hiring new employees.
According to Walden University (2018), the Triple Aim of healthcare, which is increasing access to healthcare, improving clinical outcomes, and reducing the cost of healthcare delivery, was converted to Quadruple Aim with added focus on environmental effects that include work life and provider experience improvement (Walden University, 2018, 1:15; Periera & Bowers, 2021, p. 69). Hence, one of the reorganizational strategies and health system work setting response to the healthcare issue of staff shortages would be enhancing employees’ well-being and experience. Jacobs et al. (2018) noted that “making well-being an organizational strategy could be a way to improve employees’ lives while achieving organizational outcomes” (p. 232). The authors overviewed Anne Arundel Medical Center’s approach to enhancing employees’ well-being, including educational opportunities, career development, social, financial, and physical expansion, and assuring community support (pp. 236-237). ProMedica healthcare organization also provides diverse programs to support employees in their daily work life, particularly during hardship times. Thus, ProMedica launched Employee Assistance Program (EAP) that offers mental health counseling, stress management, substance abuse consultation, solution support, and is open for employees 24 hours via telehealth, phone, or in-person counseling (ProMedica, 2023). Additionally, ProMedica ensures employees’ wellness via 24/7 telehealth support for adverse health conditions, unemployment protection, and family/parental support.
Another reorganizational strategy and health system work setting response to staff shortages would be engaging the nurse practitioners (NP) workforce to support primary care providers. Norful et al. (2018) noted that one of the reorganizational models “includes having more than one primary care professional comanaging the same patient and sharing the workload responsibilities or care management tasks” (p. 250). The authors noted, however, that current legislation and organizational policy restrict nurse practitioners’ authority leading to a “physician-led hierarchical infrastructure in which the physician has the final decision-making authority” (p. 252). The authors further collaborated that perceived NP lack of authority can be mitigated by NP-physician shared philosophy of care, mutual respect and trust, and effective communication, which, in turn, will be beneficial “to meet demand of patient care” and alleviate “individual provider workload” (p. 253). Lovink et al. (2017) confirmed that the collaborative work model of NPs and physicians and even the substitution of elderly care physicians (ECPs) by NPs, physician assistants (PA), or registered nurses (RN) is possible if NPs, PAs, and RNs are supported by management and physicians, “collaborating with the ECP based on trust, [and] sharing the same views with the ECP on good resident care” (p. 9). The SNF where I work is at the beginning of adopting this model. With only four primary care physicians for a 200-bed facility, organizational management attempts to assign certain patients to third-party organization nurse practitioners who work discordantly with the facility’s permanent physicians and nursing staff. More efforts should be made to advance the education of already employed RNs to NPs and promote collaborative work with primary care physicians in the facility.
Finally, working synergistically with educational underprices and providing a launching base for new nursing assistances and nurses can serve as an additional reorganizational strategy and health system work setting response to the healthcare issue of staff shortages. According to Jean (2022), such innovative approaches as “training new technologies, […] providing a ‘flexible workforce,’ [ensuring] personalized educational opportunities, […] or providing tailored educational opportunities” are effective ways to address healthcare personnel shortages (Using Innovation to Address the Nursing Shortage section). The author pointed out that the nurse residency programs effectively combine learning opportunities for nurse novices and fill in the gap of nursing staff shortage (Using Innovation to Address the Nursing Shortage section). For example, the SNF where I work effectively uses its settings as an educational platform to prepare nurses and nursing assistances. Many students who graduated from local community colleges decide to apply for a job and continue working in an already familiar environment.
Therefore, searching for working model reorganizational strategies, such as enhancing workforce well-being, promoting a collaborative approach of NPs, RNs, and physicians to centered patient care, and enhancing educational opportunities in both ways offering tuition reimbursement programs and serving as an educational practice site, is an effective way to recruit new healthcare team members and retain the already existing workforce.
The challenge of training nurses has been a national healthcare issue in the healthcare industry. Having well-trained nurses is essential to ensuring patients’ highest quality of care. It contributes to ensuring that nurses have the information and abilities needed to effectively carry out their tasks and care for patients in line with accepted standards of practice. Efficient and effective clinical training for nurses is required to ensure that healthcare is provided efficiently (Will et al., 2019). Although the lack of enough skills for nurses is particularly pertinent in the rapidly changing technology environment and increasing complexity of care delivery, this issue must be addressed (Ricketts et al., 2013). This issue can potentially impact my work setting as it could lead to making mistakes in delivering medical care, resulting in poor patient outcomes, incorrect diagnoses, incorrect medications, or even missed symptoms that can have serious health consequences.
In my work setting, we have responded to this issue in several ways. First, our organization has provided ongoing training and workshops for nurses. This training focuses on the role of nurses and the importance of collaboration and communication. We have also implemented an electronic health record (EHR) system to help streamline the workflow and reduce the burden on nurses. The (EHR) system has improved the quality of care, lowered costs, and improved productivity by making care more efficient and effective (Negro-Calduch et al., 2021). Finally, we have implemented several initiatives to increase nurses’ satisfaction, such as flexible scheduling, mentoring programs, and educational opportunities. In conclusion, this challenge of training nurses must include regular workshops and conferences, implementing an EHR system, and improving nurses’ satisfaction. Our firm is working to guarantee that healthcare is delivered effectively and efficiently through these ways.
Review of Current Healthcare Issues
Nurses make up the largest section of healthcare professionals and according to the US Bureau of Labor Statistics, the need for nurses is expected to grow from 2020-2030 (Haddad et al., 2022). Possible causes of the current nursing shortage include, lack of educators and high turnover rate. With the aging of the baby boomer generation, there will be an increase need of care for the elderly, as their health progresses. Another factor that lead to our current nursing shortage is the Covid-19 virus, this virus increased the demands for nurses and the volume of patients being seen (Turale & Nantsupawat, 2021). The purpose of this discussion post is to discuss the national nursing shortage and how it affects my workplace.
Nursing Shortage Impact on Emergency Department
In the emergency department we see critically ill patients every day, and it is our job to triage and appropriately place the patient where they need to go. This can be challenging when there is an increase in volume of patients in the department and a shortage of nurses to care for them. Nursing shortages in the emergency room increase the door to discharge length of stay and increase the number of patients that leave before being seen (Ramsey et al., 2018). Some social determinants affecting the nursing shortage are stress from increased workload, and negative effects on mental health. Another determinant is the Covid-19 virus and nurses fear of infection and possibly death (Turale & Nantsupawat, 2021).
Workplace Response to Nursing Shortage
My workplace has made many efforts to increase nurse retention, hire more nurses, and decrease nurse workload. My workplace is offering nurses a ten thousand dollar sign on bonus in exchange the nurse has to stay at my organization for two years. The first half of the bonus is given after their first ninety days and the other half after one year. For their current employees they are giving them yearly raises, annual incentive bonuses, and a bonus for extra shifts worked. To help decrease the nurses work load the emergency department has hired medics to help with tasks like, IV insertion and triage. Lastly, to eliminate unsafe nurse to patient ratios, they hired travel nurses to fill in holes in the schedule. In conclusion, with my employer taking these steps to improve the nursing shortage, we have already seen an improvement in the department.
The national healthcare issue and stressor I selected for analysis is the nursing shortage. When we dissect the healthcare team in the hospital setting, the majority of these professionals are nurses, who play a crucial role in healthcare. Since the pandemic hit in 2020, the nursing shortage has been growing and continues to be a huge concern. The US Bureau of Labor Statistics projects that more than 275,000 additional nurses are needed from 2020 to 2030 (Haddad et al., 2022).
I currently work in the emergency department of a small rural hospital and the nursing shortage has affected us tremendously. We have a total of 22 beds which includes two code/trauma/treatment rooms. One of these rooms is designated for the providers, and two are for storage. So, we technically have 17 rooms for patients in total. As of last August, our MOSU unit closed due to the nursing shortage, so the ER also rooms observation and admitted patients. The staffing for our shifts is one charge nurse, two nurses, one provider, and three days a week one HUC. To give a better idea of how stressful this can be I will provide an example. Last week we had a total of nine admits which left us with eight beds total for ER patients. Keep in mind, this means each nurse has three holds and must also take care of the patients that come into the ER.
With that being said, we have recently been informed that all but two of our doctors will be leaving. The number of patients the providers had to see was already high and the fact that we have to house the holds makes it even worse. These providers are stressed out and could have had some relief with a midlevel provider. The number of NPs and PAs is growing rapidly, in part because of shorter training times for such providers as compared with physicians and fewer institutional constraints on expanding educational capacity (Auerbach et al., 2018). The nurses in the emergency department are burned out and really need more help too. You would think the hospital would offer some kind of incentive for working under these conditions, but they don’t. Cecilia K. Wooden from the Walden University (2015) video states that velocity and vitality are important aspects of balancing work-life balance. She states that the workload we encounter causes stress, and we need to balance that with utilizing employee wellness programs to avoid burnout.
Social determinants that affect this healthcare issue are nursing burnout, location, and the low pay offered at this hospital. In this hospital, ER nurses are also practicing as floor nurses and most have never done that which can be stressful and pose a risk for the patient. This hospital is also over an hour away from the city and most people don’t want to make the drive there. The company needs to increase the pay to make up for the drive these nurses would have to make, and they don’t. As stated above, they also don’t have any kind of employee incentive programs for anything. Nursing burnout is very high here due to all of this. According to Jacobs et al., 2018 “Engaged employees who feel cared for by their employer through initiatives like our WellBeing programs positively influence an organization’s performance”.
The admin and nursing director haven’t done much to try and help alleviate these problems. The most they have done is place an ad online to their facebook page to advertise job openings. They haven’t even offered anything to the providers that are leaving. The quadruple-aim study includes provider satisfaction, and this hospital does not follow this aim at all. In an effort to address these aims, healthcare leaders must identify new priorities not only for healthcare delivery but to improve the work life of the members of the healthcare team (Broom & Marshall, 2021).
Healthcare Issue/Stressor and Impact on Work Setting
Lack of access to healthcare has always been an issue healthcare organizations have been combatting for years. Before the pandemic, there was a multitude of social determinants that created barriers to access to health care. The pandemic, however, was clearly the most significant determinant that destroyed access to healthcare exponentially compared to the determinants that were already an issue previously. This impacted the work setting because there was an increased demand for emergency services since many patients needed help to follow up with primary care providers or specialists. My hospital stopped elective procedures from having rooms for critical patients with life-or-death necessities. Staffing shortages became an issue, and we began to notice decreased patient and worker satisfaction due to higher nurse-to-patient ratios and increasing demand for nurses and doctors. Despite the significant increase in demand for medical services, the supply of medical professionals is not growing fast enough to keep up with the demand. Physicians need to outsource their work, new technologies are being developed and more duties are falling on APRNs and clinicians that are not physicians (Auerbach et al., 2018, p.2358-2360).
Social Determinants Affecting this Healthcare Issue
Covid-19 was the primary determinant preventing access to healthcare, and facilities had to pivot with their technology to remain current and competitive. However, before covid-19, there were other determinants facilities were already taking actions to reorganize processes to improve outreach and services to the sickest patients. . Income and poverty restricted access to those individuals who were struggling to afford services or medication and could also limit access to transportation to healthcare facilities. Low education levels affected access due to illiteracy which sometimes delayed seeking healthcare services until problems progressed. Location and proximity to services hamper access and have always been an issue if patients travel 1-2 hours to see their providers. As you can see, the Roe vs. Wade situation currently limits access to reproductive services for women. There have always been social determinants that need to be combatted to improve access for our population with a focus on minority groups and the underserved long before covid-19 turned off all the lights. Systems need to be altered at times which sometimes means certain tasks need to be outsourced and loosely controlled or remain in house and tightly controlled by the faculty. Creativity and flexibility in new processes is key to be able to adapt effectively (Pittman & Scully-Russ, 2016, p. 2-3).
How Work Setting has Responded to this Healthcare Issue
In combatting these social determinants leadership needs to get creative and evolve with the times to ensure their business will continue to grow through the difficult times. New systems need to be developed to meet ever changing needs of the community in challenging times of change (Broome & Marshall, 2021, p. 35-36). My facility has increased access to telehealth services after discharge to monitor patients and ensure they remain proactive in their mental health and stay engaged in their care. Low-cost or free services are sometimes granted to low-income individuals and families who have difficulty paying for assistance but have critical needs for access to remaining focused and stable in the community. Telehealth has become the forefront of the next generation of healthcare, improving access to millions of people living in rural areas or hours away from the nearest provider.
Nursing Shortage
National healthcare issues directly affect how a healthcare organization functions. One national healthcare issue directly impacting the healthcare organization where I work is nursing shortages. Nurses are a vital part of healthcare. From 2020 to 2021, the supply of registered nurses (RNs) decreased by more than 100,000, creating an additional strain on an already suffering healthcare system following the COVID-19 pandemic. Factors that contribute to the nursing shortages are nurse burnout, an aging workforce reaching retirement age, family obligations, a lack of nursing educators, and an aging population with chronic diseases. Nurse shortages affect direct patient care by creating high nurse-to-patient ratios, thus leading to increased medication errors, infection rates, higher morbidity and mortality rates, and increased nurse burnout. Also, nurse shortages affect direct patient care by limiting the number of hospital beds available to care for patients. A healthcare organization needs a nurse to care for its patients. The nursing shortage will leave hospitals with empty rooms due to limited nursing staff available. This causes hospitals to diverge patients to other hospitals and can decrease funding and reimbursements (American Association of Colleges of Nursing, n.d.; Broome & Marshall, 2021; Buerhaus, 2021; Jones & Spiva, 2023).
Impact of Nursing Shortage
The healthcare issue of the nursing shortage directly impacts my workplace healthcare organization by decreasing the beds available in the emergency department. Currently, I work in a rural healthcare organization. The closest level-one trauma center is over one hour, with limited ambulance services available. My healthcare organization is a critical access point for this rural area. The nursing shortages have decreased half the emergency department’s nursing staff, causing the healthcare organization to close over half the number of beds available. Thus, causing a delay in patient care and limiting the services available to the community (American Association of Colleges of Nursing, n.d.).
Social Determinants of Health
The social determinants of health most affected by the healthcare issue of nursing shortage are Health Care Access and Quality. The limited number of nurses available to care for patients and the financial strain that the nursing shortages had applied to healthcare organizations have decreased patient access to healthcare, especially in rural and low-income areas. Also, nursing shortages have affected the quality of patient care by causing higher nurse-to-patient ratios, thus leading to increased medication errors, infection rates, and morbidity and mortality rates (American Association of Colleges of Nursing, n.d.; Broome & Marshall, 2021; Buerhaus, 2021).
Responding to the Nursing Shortage
My healthcare organization has yet to succeed in responding to the nursing shortage. The only action they had implemented was a sign-on bonus with a one-year contract. However, their pay does not compete with other larger healthcare organizations in the surrounding areas. The administration is currently discussing and holding meetings with nursing staff and providers to form an action plan to retain and recruit nurses.
The national healthcare stressor I’ve selected is the growing nursing shortage. I think it’s safe to say that we all feel the weight of this stressor daily in our working lives. Many facilities, including my own, are constantly working short-staffed. We have an aging population with increasing complexities in healthcare needs and a decreasing supply of current and future nurses (Morris, 2022). In my state of Virginia, there’s only 10-12 nurses per 1,000 residents (Nurse Journal, 2020). This is dangerous for our patients and for us as nurses. Patients may not receive adequate care and nurses are at risk of losing their licenses due to unsafe practices and high ratios.
The main social determinant affecting this issue is geographic location. Many nurses are moving to hiring paying areas, leaving lower paying areas without adequate staff. Thus, leading to the rise in reliance on travel nurses and per diem staff. Contract hires are wonderful resources to use in times of need, however, it is so important to have a strong core staff to keep units up and running efficiently.
My facility has tried to combat this by hiring new graduates to practice in high levels of care and by taking advantage of travel and per diem employees. The practice of using travel and per diem employees is expected to rise to combat the nursing shortage overall (Green, 2023). New graduates can do well in higher levels of care IF they have adequate orientation. Unfortunately, due to the nursing shortage, many new graduates are being pressured to come off of orientation early. This can be detrimental to both the nurse and their patients. I would like to see my facility offer incentives for new hires and for current staff, as this is something that is currently lacking.
War on Women’s Health:
On June 24, 2022, Rowe v. Wade was overturned by the Supreme Court, leaving it up to each state to decide whether the practice of abortions would be legal or not in their condition. This impacted our healthcare system, especially regarding women’s health, nationwide.
Restrictive abortion regulations in states can limit access to safe and legal abortion services. This can increase unsafe abortions, resulting in serious health complications and even death. Abortion regulations can also impact reproductive health outcomes, including unintended pregnancies, maternal mortality, and morbidity. This makes healthcare providers uneasy when it comes to providing care for these patients without being put at risk for legal and regulatory barriers to providing abortion services, which can limit their ability to provide the full range of reproductive healthcare services (Harris, 2022).
In the state of Ohio, which is the state I reside and practice as a Registered Nurse, abortion laws are more strict. According to (Field et al., 2022), “Ohio abortion regulations limit ob-gyns’ ability to provide comprehensive reproductive health care, creating ethical dilemmas for these physicians as they attempt to care for their patients. As Ohio’s abortion laws increase in number and restrictiveness, they further undermine obstetric and gynecologic ethical practice guidelines.” This can also impact the ability of healthcare providers to provide evidence-based care, which can impact health outcomes. The healthcare organization where I currently work often has to refer patients to other clinics in states where access to safe abortions is available to them when they need one.
Abortion regulations can also impact social determinants of health, such as access to education and employment opportunities, and can perpetuate social and economic inequalities (Carroll, 2022). These regulations can disproportionately affect low-income women, women of color, and those living in rural areas, who may have limited access to healthcare services and may be more vulnerable to the negative impacts of restrictive abortion policies (Redd et al., 2022). Women unable to obtain abortions may be forced to continue pregnancies unprepared, impacting their ability to work, attend school, and care for their families.
How can the health profession address the needs of the many where there are only a few? The healthcare profession has faced a multitude of factors keeping up with the demand of the census. Ranging from meeting the population’s medical needs in rural areas or providing primary care to the overall census due to the shortage of physicians. Physician shortage may be due to extended training time vs. acute need for primary care and a lack of medical school capacity. In addition, the limited accredited residency position(Auerbach et al., 2018). In addition, the aging population of physicians shows that within the next decade, more than 2 out of every five practicing physicians will be over 65(Jubbal, 2022). The Association of American Medical Colleges projects the physician population will only increase by 0.5%-1% per year between 2016 and 2030(Auerbach et al., 2018, para. 2). However, researchers believe in offsetting the slow growth of the physician population, the number of physician assistants and nurse practitioners will continue to sour in development by 6.8% and 4.3% annually. Therefore, Nps and PAs contribute more than two-thirds (67.3%) of all practitioners between 2016 and 2030(Auerbach et al., 2018, para. 6).
Nurse practitioners are equipped with the education and capability to fulfill the gap between the need for clinicians and providing high-quality cost-affected care to the population in need. Some of the duties of a nurse practitioner are to assess and perform physical examinations, order and analyze cost-efficient diagnostic tests, consult fellow health professionals to aid in the treatment of the patient, prescribe the appropriate medications, and follow up on the individual’s status to reduce readmission and improve the patient outcome.
NPs consistently demonstrate similar or better outcomes than their physician colleagues across various health indicators(Buerhaus et al., 2015). However, “the increasing number of Nps alone will not address the deficiencies in primary care delivery because many policy and practice setting barriers affect Nps’ ability to offer services at the full range of their educational preparation and competencies” (Broone & Marshall, 2021, p. 77). Currently, 28 states out of 50 have limitations on the scope of practice for nurse practitioners mandating signatures for care to be signed by physicians.
Currently, I reside in Virginia. Virginia has a limited scope of practice for nurse practitioners. However, nurse practitioners and physicians provide comanagement upon treatment to patients, but the physicians have the final say in the direction of care management. I like this format from a new nurse practitioner aspect, but after becoming comfortable in my role. I want more autonomy.
Nursing shortages and staffing concerns have been and continue to be major issues in healthcare. There are myriad reasons for staffing shortages in the nursing field. The aging workforce is seeing many more nurses retire than become new nurses. The nurses that remain want more time with their families. An increase in violence in the workplace, job dissatisfaction, and burnout are also some of the factors that lead to the lack of a nursing force worldwide (Haddad et al., 2022). One study suggests that by 2035 there will be a shortage of over twelve million nurses (Marć et al., 2018). More nurses are working in non-hospital settings such as Home Care, community health, and outpatient settings (Palumbo et al., 2017). This shift in locations of medical care is one of the contributing factors in the decline of hospital staff.
Nursing shortages are affecting all nursing fields, even the areas where the above study indicated the shift is helping. In my particular home care agency, we are currently looking for nursing staff for patient care. Despite offering more than the national average salary (Marć et al., 2018) we are unable to find qualified candidates. Due to the lack of appropriately qualified applicants, we are forced to make decisions between overextending our staff or curtailing patient interactions. Our agency has attempted to mitigate the stressors involved with nursing by implementing set hours of operation, focusing on employee wellbeing, increased training, and placing our nurses in the community where they live (Jacobs et al., 2018).
As I said earlier, there are many factors that play into the nursing shortage. Some of the determinants are a lack of educators to teach nurses, the regionality of the field, nurses retiring, more people needing care as the population ages, and an uptick in violence against healthcare workers (Haddad et al., 2022).
Nurses are critical to the makeup of healthcare. As times continue to change the profession of nursing continues to face shortages as a result of a lack of education, an increasingly high turnover rate, and an unequal workforce distribution. Nurse burn out rates are increasing tremendously. Many times, nurses are finding that once they start their profession in healthcare, they then decide the career is not for them. The national average rates in the United States for turnover have increased from 8.8% to 37.0% (Haddad, et al., 2022).
I work as a labor and delivery nurse in a small community hospital. It is incredibly evident within my hospital; nursing burn out is real. Being that I work in a small hospital, it seems that more and more hats get added to our heads. Overtime, this creates hardships for nurses. Nurses feel they cannot care for the patient the way the patient should be cared for because of all the extra jobs being added to their already overflowing plate.
Social determinants of health (SDOH) are what impacts individuals’ health and well-being. Included within SDOH are economic stability, good quality and access to education, access to quality healthcare, access to opportunity of physical activity and nutritious foods, and safe housing (U.S. Department of Health and Human Services, n.d.).
The social determinants that most affect this health issue would be the determinants of physical and mental health. Healthcare professionals experience emotional exhaustion and a lack of confidence when physical and mental health is at stake. Addressing these social determinants of health can help by combating the healthcare burnout issue. (Heath, 2019).
My hospital has recently implemented sign on bonuses and retention bonuses to help with nursing burnout and nursing shortages amongst the hospital. The has helped because those who decided to sign must commit to a two-year contract. The hospital also worked to put together a serenity room for staff to use. These things have helped, but there is still a lot of other changes that need to be made in order to assist with this healthcare issue.
Burnout and work-related stress
One national healthcare issue/stressor affecting my work setting is the nursing shortage, lack of supporting staff, and sudden changes that have led to burnout and work-related stress. Nurse burnout impacts patient healthcare outcomes and contributes to a poor work environment (Lajiness, 2022). I work at a military medical center, and most of the time, changes come down the pipe without the opinions of the staff involved. In 2020, when covid pandemic hit the world and affected the healthcare system, my ward was changed to be the designated covid unit. The ward was a locked unit, with no warnings and no training on the expectations of things to come. In 2022, when the war in Afghanistan was over, and the military base was closed, the injured Afghanis when brought to our hospital, and the unit was shot down again. Once more, we cared for patients who spoke no English, did not want women to touch them, and seemed hostile toward us. These two events created a lot of workplace-related stress and burnout. Leadership made all the decisions, and we had no say in whether we could support this mission. At the same time, most of the military staff were deployed to different states where the covid numbers were rising. So we were short-staffed and dealing with these changes. According to Hetzel-Riggin et al. (2020), one factor that affects the nursing shortage is an unfavorable and declining work environment which leads to job dissatisfaction. Nurses started looking for jobs in the outpatient environment where changes are predictable. According to Hetzel-Riggin et al. (2020), five different types of burnout symptoms can be observed: physical (such as sleep disturbances, headaches, and gastrointestinal problems), emotional (such as irritability, depression), behavioral (such as poor work performance, increased absenteeism), interpersonal (such as withdrawal from others), and attitudinal (such as callousness, dehumanization of clients/patients). One staff member retired, and two others left. Losing staff members with the skills set and experience is devastating and often leads to low-quality care and poor patient satisfaction.
Social Determinant
The social determinant mostly affecting this health issue is employee well-being. Jacobs et al. (2018) suggested that the work environment significantly impacts employee well-being, and employees with poor well-being were less engaged and more pessimistic about the workplace. The morale was very low amongst the staff. There was no trust in leadership, especially after we lost a staff member during the pandemic.
After our concerns were brought to the leadership and we had a unit meeting, the following changes were made;
- Our ward was removed from the list for any sudden changes without conversing with the staff.
- A quiet room with a massage chair was provided for us where we could go there to center ourselves.
- The lunchroom always had healthy snacks and fruits.
- Hospital-wide for civilians with at least one year with the federal government tuition assistance from $6000 to $8000 annually.
- Staff is allowed to use the gym and swimming environment during working hours if staffing is appropriate.
There is still work to do, but employee satisfaction has improved for now, and we celebrate each other. Patient satisfaction has improved; our unit has won the daisy ward twice.
Health Insurance and Low-Income Population
One national healthcare issue that can affect family clinics is the lack of access to affordable healthcare services for low-income families. Many families who cannot afford private health insurance or out-of-pocket medical expenses rely on public healthcare programs like Medicaid and CHIP (Cha & Cohen, 2022). However, these programs may have limited coverage or may not cover certain services, leaving families with limited options for healthcare. This can strain family clinics, which often serve low-income populations and may be reimbursed at lower rates for Medicaid and other public insurance programs. Family clinics may need help providing the necessary care and services to these patients while balancing their financial needs.
The shortage of primary care physicians in certain areas can also affect family clinics, as they may need help to recruit and retain qualified healthcare providers. This can limit the availability of healthcare services for families in those areas and strain existing staff. Addressing these healthcare issues and improving access to affordable, quality care is crucial for supporting family clinics and ensuring all families have access to the care they need (Cha & Cohen, 2022).
Social Determinants
A lack of access to affordable healthcare services can affect several social determinants. To name a few,
- Health outcomes: Lack of access to affordable healthcare services can lead to poor health outcomes, including increased rates of preventable diseases, chronic conditions, and premature death.
- Economic stability: When individuals cannot access affordable healthcare services, they may face high medical bills, leading to financial instability and bankruptcy.
- Education: Lack of access to affordable healthcare services can impact education, leading to increased absenteeism and decreased academic performance.
- Employment: When individuals cannot access affordable healthcare services, they may miss work due to illness or injury, leading to decreased job productivity and loss of income.
- Social and community context: Lack of access to affordable healthcare services can impact social and community context by leading to increased stress and decreased social support, which can negatively impact mental health.
- Physical environment: Lack of access to affordable healthcare services can impact the physical environment by increasing exposure to environmental hazards and decreasing access to safe and healthy living conditions.
- (Artiga & Hinton, 2018).
The lack of access to affordable healthcare services can significantly negatively impact individual health and social and economic well-being.
Affected Workplace
Limited access to healthcare for low-income individuals can affect family health clinics in several ways. Family health clinics that serve low-income populations may experience an increase in demand for services as individuals who lack access to other healthcare options seek care. This can put a strain on clinic resources, including staff and funding. Many clinics need financial stability because of providing care to low-income patients who are uninsured or underinsured. These patients may need help paying for services or may be covered by public insurance programs that reimburse at lower rates, resulting in financial challenges for the clinic. Not only does it affect the clinic, but limited access to healthcare in low-income communities can also lead to challenges in recruiting and retaining qualified healthcare providers. Family health clinics may struggle to attract providers due to lower salaries or lack of resources, making it difficult to provide consistent patient care. Lastly, when low-income individuals cannot access necessary healthcare services, it can lead to adverse health outcomes for individuals and families. Family health clinics may see patients with more advanced or chronic health conditions because of delayed care, which can be more difficult and expensive to treat.
Healthcare for low-income individuals can significantly impact family health clinics, affecting demand, financial stability, staffing, and health outcomes. It is essential to address healthcare disparities and improve access to care to support the health and well-being of families and communities.
The scope of healthcare delivery extends beyond disease treatment to include preventative care, routine checkups, and emergency care. Accessibility, shortages of medical professionals, antiquated equipment, and other problems all contribute to our country’s trouble in providing medical care to its citizens. Low quality of service and poor health outcomes, longer wait times to obtain care, harm to the institution’s image, a loss of patient trust, and a lack of accreditation are all direct results of healthcare delivery problems. (Broome & Marshall, 2021).
The organization has hired several APRNs to enhance service delivery in the face of physician shortages in primary care outpatient settings (APRNs). In Maryland, advanced practice registered nurses (APRNs) have the authority to conduct patient assessments, order and interpret diagnostic tests, make medical diagnoses, and launch and oversee treatment plans independently. They can also write prescriptions for drugs and treatments. These rules provide APRNs complete independence in the workplace and serve as a means of speeding up healthcare delivery. Healthcare delivery may be enhanced by resolving the problem of patient access to services. Integration of telemedicine services is one way to achieve this goal. In response to the COVID-19 pandemic, numerous healthcare facilities have used telemedicine, which has helped APRNs with triage services and improved high-risk patients’ access to regular treatment. Moreover, it has assisted persons with mental health conditions to maintain access to the necessary therapy services. Most importantly, it has allowed people with mental health issues to keep accessing the treatment they need via therapy (Smith et al., 2020).
Hence, the organization has hired nurse informaticists who have developed tools to improve healthcare delivery. According to Darvish et al. (2014), the new wave of technology has allowed new communication channels between doctors and their patients. Nurse informaticists utilize their knowledge to improve patients’ health, develop better healthcare systems, and make their jobs easier. A nurse informaticist develops software that facilitates electronic communication between nurses and other care team members, as well as between nurses and patients.
Across the United States, there are many different healthcare issues that can affect workplace settings. One workplace setting issue or stressor that many are facing is nursing shortages and burnout. There has always been a need for nurses and a shortage, however since Covid-19 has come into play, the shortage/burnout has become more of an issue. With Covid-19 nurses are expected to work more days, longer hours and patient/nurse ratio has gone up. There are not enough nursing students that are passing school and able to join the workforce. Another part of this is nurses are leaving the field all together due to the constant stressors. I work in the clinic, however we see a shortage in nursing in the clinical setting as well. Within my rural facility, nurses are being pushed to do the job of 2-3 nurses during clinic hours while also maintaining patient safety. “The nursing profession continues to face shortages due to a lack of potential educators, high turnover, and inequitable workforce distribution” (Haddad, et al, 2022).
With a nursing shortage/burnout there is no one social determinate that is affected. All of healthcare and patients are affected by nursing shortages. With that said, one social determinate that is affected are psych/mental health patients. This field is already a low retention rate area to work and since the pandemic this number has increased. According to the American Psychiatric Nurses Association 2019, “More than 75 percent of all U.S. counties have a shortage of any type of mental health worker and 96 percent of all counties have an unmet need for mental health prescribers.” Since this, it has continued to become more of an issue.
Within my facility, they have had multiple different attempts in helping with nursing burnout/shortages. One of which is large retention bonuses. These bonuses are given in payments across two years. Our current largest bonus is $25,000 spread across the 2 years and I believe to be twice a year. The longer the staff is with the more money they receive. While this is a nice thing to have, it is hard to still work through the hard times of working shorthanded. Floor nurses are being called in on their days off and end up working 4+ 12 hour days instead of working their scheduled 3 days. Another way the facility is attempting to keep nurses is offering tuition assistance to go back to school. Once staff sign up for tuition assistance, they are signed in for one year after graduation or they must pay all the money back. Nurses are encouraged more and more to continue on with their education and more facilities are wanting BSN nurses vs RN’s. My current facility has specific colleges they help pay for and according to Gerardi, Farmer & Hoffman, 2018, “…employment-focused partnerships between schools and health care facilities that provide students with practice experience, promote greater use of the BSN, and create employment opportunities.” This is a great way to encourage nurses to continue on in their education and retain employees as well.
The nursing shortage is real and it is here to stay. With the increase in demand for nurses, nurses being unable to pass schooling or finding qualified schools to attend, the nursing shortage is here to stay. Because of nursing shortages, nurses are being put in unsafe situations not only physically and mentally for them but also the patients in which they see/treat. “Patient outcomes are affected by staffing shortages. High nurse-to-patient ratios can lead to medication errors and higher morbidity and mortality rates” (Morris, 2022).
The national healthcare issue I chose to analyze was that of opioid addiction. This issue directly impacts the care of every single patient I see. Throughout the pandemic we started using more opioids to treat pain in our patients whether covid positive or just being seen for every day issues. Not only is dependency a huge issue with opioids but the number of overdoses has increased rapidly throughout the years.” More than 932,000 people have died since 1999 from a drug overdose.1 Nearly 75% of drug overdose deaths in 2020 involved an opioidLinks to an external site.” (“Data overview,” 2022). This directly affects my work setting for many reasons, we must make sure that the proper medications are being given to patients, in proper doses and that we don’t overmedicate or use medications the patient may not truly need. Social determinants that are seen with opioid use include but are not limited to, a person’s income, a person’s housing stability or living situations in general, education regarding the use and addictive properties of opioids (“Social Determinants of Opioid Use among Patients in Rural Primary Care Settings,” n.d.). As far as addressing this crisis in the healthcare setting, more physicians are less likely to prescribe opioids for generalized pain and prefer to use a multimodality form of pain control. This includes using heat and ice, using creams to address pain, lidocaine patches, alternating Tylenol and ibuprofen. While there are certainly situations in which opioids are needed a deeper look is being taken before just prescribing and giving these medications especially with patients who have previous abuse histories.
In the field of Women’s Health, particularly Labor & Delivery, Antepartum and Postpartum care, the national standards of care and patient ratios are provided by AWHONN, Association of Women’s Health, Obstetrics and Neonatal Nurses (AWHONN, 2022). These standards of care, which include safe practice guidelines for patient to nurse ratio, are updated on a frequent basis.
Most large hospitals and teaching facilities adhere very well with patient:nurse ratios as set forth in the AWHONN guidelines, however there are exceptions when acuity and lack of staffing require the ratios to be tilted and the patient/nurse ratio to be overextended. The Women’s Health Departments in smaller, more rural hospitals tend to not adhere to these guidelines, oftentimes causing very unsafe staffing ratios and place an overbearing load on nurses within their Women’s Health units.
Unit policies are created within each facility, sometimes policies are set forth by upper management that have never staffed the unit or understand how these guidelines are there to protect both patient and caregiver. However on the other end of the spectrum there are hospitals that have policy makers that are all clinical staff. The policies set forth by both nurse managers, attending physicians, and nursing staff are most often policies that are easy to follow, understand and provide the best patient care guidelines (ACOG, 2022).
Within each of the departments making up the Women’s Health Unit, both management and nurses often times participate in the leadership role and participate closely with policy and procedure. Both in writing policy and preparing the procedural flow, nurses transition into a leadership role. According to Boome, “leadership is the ability to guide others, whether they are colleagues, peers, clients, or patients, toward desired outcomes” (Broome, 2021). The role of the nurse is multifaceted, as with the policy and proceedure at different hospitals and facilities across the country, As participants in the policy and procedure arena nurses take on the role as a transformational leader, where as nurse leaders one can influence others by changing the understanding of others, to what is important in the care of patients, family, staff (Broome, 2021).
Changing policy and procedure is a process. It is not just one thing, it consists of many characteristics and is an evolving process. As nurse leaders we can participate in these changes, use our knowledge of national guidelines and governances to assist in exceptional results within our hospitals and facilities.