The nursing shortage in the United States has ebbed and flowed for decades, but the pandemic has exacerbated our current nursing deficit. A 2021 McKinsey survey cited 22% of direct-care nurses were considering leaving their positions within a year due to inadequate staffing levels, extreme workloads and the job's physical demands.
Compounding this challenge is that prospective nursing students are being waitlisted due to a lack of instructors. Data released by the American Association of Colleges of Nursing (AACN) showed that 80,521 qualified applications were turned away in 2020 from nursing schools primarily due to shortages of clinical sites, teaching staff and resource constraints. But an additional 200,000 nurses will be needed by 2029, the AACN projects. Some institutions are turning to a lottery system to reduce the number of accepted applicants.
These tough issues are further complicated by these factors: the demand for patient care is rising, we have an educational system that can't keep up with surging enrollment and hospital systems are also facing their worst financial crisis in recent years. The solutions to the nursing shortage are complicated, but they aren’t impossible. The Journal of Nursing Administration has published multiple pieces about ways to solve and stabilize the nursing crisis.
The American Medical Informatics Association (AMIA) recently hosted the National Burden Reduction Collaborative (NBRC), sponsored by Epic, during the AMIA 2022 Annual Symposium. It’s a collaboration with the Association of Medical Directors of Information Systems and the Alliance for Nursing Informatics.
“The NBRC spent two days sharing their ongoing research, knowledge and initiatives around documentation burden and clinician burnout reduction to understand organizational priorities and align efforts,” an AMIA press release stated,
The use of technology is being considered to help address the nursing shortage. Using the 2021 McKinsey survey as our guide, we ask Nancy Beale, Ph.D., MSN, R.N.-B.C., how technology can both support the current needs of overworked nurses and assist with alleviating some of the persistent problems responsible for the nursing shortage.
Online education can help alleviate the instructor shortage when the coursework doesn't require teachers and students to be physically present in a classroom. Technology helps with virtual learning, although it won't completely replace traditional instruction. Virtual reality (VR) simulation and high-fidelity simulation that uses realistic, life-like manikins (a full-body patient simulator) to mimic human anatomy and physiology are already being used by training programs to teach clinical skills safely in a controlled environment.
There are several scenarios where technology plays a role, and that role can be positive or, at times, negative. Overall, technology is most helpful whenever it can do the heavy lifting so that a nurse is not manually gathering or sorting through data to understand their assignment or what's going on with a patient.
For example, some institutions will interpret the satisfaction of certain regulations as something they can simply add to a nurse’s workflow, such as patient data collection for documentation. Before you know it, a nurse has an extra hour they must spend with the patient just to do their admission, and that nurse may have five other patients who aren't going to see them for that hour.
I think that if you asked the nurses today working on the frontlines, stopping to meditate would be a bit of a stretch in terms of their hierarchy of needs. The more an organization can offer ways to simplify the work nurses do would be the first priority that’ll help with their satisfaction.
Some of the work I did when a new hospital tower was being built in New York was innovating around the nurse’s workflow, resulting in nurses no longer having to push medication carts around or go to the medication room. We partnered with a pharmacy organization that was already our vendor to build a new technology that provided a portal and controlled locked drawers, with all the patient-specific medications, outside every patient room. That technology was then integrated with the EHR as well as the pharmacy and inventory management system. When medications got low, the pharmacy knew they needed to be replenished.
Those kinds of efforts make a huge difference in work satisfaction. In this example, the nurse doesn't have to push the cart around the unit, allowing the nurse to spend more time with their patients. If you talk to most nurses or clinicians and ask them why they got into their profession, it’s because they want to care for the people. It’s not about the technology they use; they want to care for the people.
If the technological support that organizations provide to nurses enables them to better care for people, they will be much more satisfied in their work.
One of the challenges is when there are multiple technologies, and they're not interoperable. What ends up happening is the nurse becomes that human interface recording data from one system into another, logging in and out of multiple technologies, just to get systems to work so they can take care of their patients. Then instead of the technology doing the heavy lifting, it ends up that the human becomes a servant to the technology. Wherever possible, all data should be shared and standardized. How well technologies are connected can either create greater efficiency for nurses or it can be the demise of the day.
There are new models of care that are entering into practice and virtual nursing is one of those models. The term can be used in multiple ways, but more recently, virtual nursing is used to oversee alarms and alerts in a command center.
Pain assessments and data collection can be done remotely. So, instead of the bedside nurse trying to capture patient health data while they're also caring for patients, you can have somebody whose sole focus is to look at lab values, alarms, and alerts by physiologic monitors, etc., and then reach out when something is concerning and escalate where appropriate.
Virtual nursing is also used to do virtual telehealth visits. If the nurses are advanced practice or mid-level providers, they can prescreen, and sometimes they are the healthcare professional the patient actually meets on the virtual visit.
This type of solution is also used to assist nurses who are new to the profession. A newly hired nurse will typically be assigned to a veteran nurse to shadow and consult. However, this system adds to the senior nurse's workload and takes away time they spend with their patients. Some organizations use a dedicated telehealth line for new nurses to ask advice from more experienced virtual nurses on a phone or smart device.
There is a lot of innovative work around chatbots, for example, that have a human appearance and dialect. But there always comes a point where it must be handed off to a real person. I think nursing will play a more significant role in the future models of healthcare. And I think the pandemic demonstrated this, not just in the acute care space, but also as critical navigators for care for people with chronic diseases like diabetes or cancer, or those who are preparing for major surgery.
There's a lot of data to consume, especially in the acute care and hospital spaces, and it's challenging for nurses to be on top of everything. Vendors provide technology and tools to gather data, but sifting through it can be difficult. And if you see one electronic health record (EHR), you’ve seen ONE electronic health record. They are all so configurable that different organizations configure records in different ways.
We see a lot of staff, especially nurses, going from one health system to another, and each time they go to a new place, it's like learning a new EHR system, even if they're all from the same vendor because they've been configured differently. In and of itself, that lack of standardization creates a burden, overhead and additional work that the nurse, physician or clinician must do to sort through to get the information they need to care for the patient. So, in that sense, a virtual strategy is very helpful.
Tech rating systems have been around for decades. HIMSS has a rating system. You'll see a score given, such as HIMSS Stage 6. Within their requirements to achieve that approval are specific workflow, safety, efficiency and analytics factors. People want to be where it's safe to practice, and efficient workflows are a priority.
I spoke a little bit about how I believe nurses will have a larger role in future healthcare value-based care models, and we're already seeing that today. One of the things that has historically not been done well is tying the work of the nurse to the outcome of the patient.
What you often see in medical records is related to diagnosis for procedural interventions that are done by a provider. Well, all the work that actually helps the patient get out of the hospital is done by nurses. Today the work of nurses, particularly in the acute care space, but even outside of the acute care space, is not recognized discreetly in technology.
There's a huge work effort right now around what is called the “unique nurse identifier,” which is a number that every nurse has once they’re licensed. When you take your state board exam, you get a unique ID from the National Council State Boards of Nursing (NCSBN). Even if a nurse is licensed in different states or relocates throughout their career, their work is all tied back to that unique ID.
This effort is being supported by the Alliance for Nursing Informatics and the Nursing Knowledge Big Data Science Group, both in which I participate, to support the use of the unique nurse identifier across technologies throughout healthcare. This will give the ability to discreetly tie back the outcomes of patients to nurses.
One healthcare organization, HCA, has been doing some pilots to look at the movement of nurses across specialties. The results of these pilots will help organizations identify what skills somebody has if they have a particular need.
Technology can only help us do this, however, if we begin to discreetly track the NCSBN ID. We are advocating that vendors of technology create a place within their system where if you identify a provider and that provider is a nurse, they ingest the NCSBN ID. There's even a free API, so vendors can include the NCSBN ID within the context of their systems, and that's another way their system could be interoperable.