Megha K. Shah, MD, MSc: Improving Nurse Satisfaction

A conversation around how burnout, COVID-19, politicization, and career progression programs influence the state of the largest US healthcare team.

New findings from a team of Emory University investigators, contribute to the understanding of why nurses, the largest proportion of the country’s healthcare workforce, may leave or at least consider leaving their job.

Published earlier this week, the survey-based cross-sectional study found that, in 2017, approximately 10% of all US nurses at least considered leaving their job. Among that group, nearly one-third (31%) claimed burnout drove their decision.

These results, which also depict demographic and regional characteristics of the nursing workforce, provide a clear snapshot of the status of a vital care team industry—one which was reporting issues in their work years prior to the coronavirus 2019 (COVID-19) pandemic.

In an interview with HCPLive®, study Megha K. Shah, MD, MSc, Department of Family and Preventive Medicine at the Emory School of Medicine, detailed her team’s research, the possible role of COVID-19 in caregiver burnout, and solutions toward improved nursing staff retention and satisfaction.

HCPLive: What your team was looking to interpret in your research into nurse burnout prevalence?

Shah: There is a survey that comes out every 2-4 years by the National Sample Survey of Registered Nurses in the US. We used their most recent data, which came out in 2018, to take a cross-sectional look at what nurses were reporting as factors associated with leaving their jobs or considering to leave their jobs.

This is a one-year snapshot where nurses were asked to self-report, 'In the last year, did you leave your job, or consider leaving your job?' We looked at those responses from nurses who left or were considering to leave their jobs, and then looked at what they reported as a reason for leaving their job or considering to leave their job. And in both these categories, over one-third of the nurses were reporting that the reason they left or were considering leaving their job was related to burnout.

Then we wanted to further look at the factors associated with why nurses were reporting leaving their job due to burnout—was it related to the type of work they were doing, the hours worked, any particular kind of personal characteristics of the nurses or their work environment that were leading to these outcomes. And what we found was there was a direct correlation with the hours they were working. They were more likely to leave their job or consider leaving their job if they're working more than 40 hours per week.

We also found the hospital setting was associated with a higher risk of either leaving or considering to leave their job. And then we found pretty significant regional variation.Nurses out West reported lower rates of burnout than nurses in the Southeast and the Northeast.

What we were interested in is that this is kind of a baseline snapshot, pre-pandemic. When you think about some of these risks, these factors—like hours worked, working in an inpatient setting—you would only imagine that, given what what sort of demands are placed on nurses right now, that this is going to be much worse if we were to survey the nurses again, in 2020 or 2021.

HCPLive: As you said, the findings seem to align with what we now hear as issues for caregivers during COVID-19. And it also aligns with previous discussions around the decentralization of direct caregivers due to payer-related responsibilities and excessive EHR logging, which has been linked to burnout. Are these factors your team observed in your findings?

Shah: In this particular survey, they asked nurses if they left their job or are considering leaving their job. Burnout, as I mentioned, was one of those options, and over one-third were reporting that. But a lot of other reasons were also reported. A stressful work environment, which can coincide with burnout as well, was also one of the top reasons that people were leaving their job.

They were leaving because of the physical demands of the job, which you can imagine those would also increase during this particular, incredible strain on our health system right now. They were leaving for better pay and better benefits—and you already are seeing that. For example: there was a story about a month ago about nurses leaving their full -ime jobs to become travel nurses, because they're in such high demand and are getting paid really well to go leave.

So, a lot of hospitals are like left with less staffing, because they just can't compete with that. And so, another reason was inadequate staffing. This is all correlational—I can't say for sure—but for example, in California, there is a state-level policy about nurse staffing in hospitals. And California has some of the lowest reported burnout as reason for leaving, compared to other states. During the pandemic, the state legislature has put that policy on hold, because of the strain on health systems in California, so they no longer are abiding by that lower nurse staffing ratio. So you might see those trends change.

HCPLive: Those seem to be self-perpetuating issues: burnout driving nurses from their jobs, and staffing shortages driving burnout.

Shah: I mean, what we tried to identify and describe was a baseline pre-pandemic status of what nurses are reporting as the things that are causing them to consider leaving their job or quitting their jobs. And what we might see is that this pandemic is going to drive a lot of that.

The other thing I will say is that in this particular survey, over 90% of the nurses surveyed were women. And the mean age was in their mid-40s. So, this population also has other incredible stresses on them right now, right? Domestic responsibilities, virtual school—they're all childbearing age, they might be moms, they might have other personal responsibilities. All of that, I would imagine, might make for a really tough forecast for the nursing workforce.

HCPLive: What about the shift of care team makeup? Does the introduction of more nursing practitioners, physician assistants, non-prescribing specialists, and the reduction of physicians do anything to affect a nurse's interest in staying at their position?

Shah: We talked about it a little bit in our discussion, that there are things that health systems do right to better support a nursing staff, which is thinking about those nurse staff ratios, opportunities for continued nursing education, better organizational leadership.

When the nurses are describing stressful work environments or lack of communication between physicians and the nursing staff, there are things around organizational culture and organizational leadership that we could think about that might improve some of those day-to-day stressors that nurses and other care providers in the health system face.

HCPLive: There's a lot of discussion around wellness programs and new methodology informed by caregiver feedback, especially in greater health networks.What are the more tangible, intrinsic details of a successful wellness program, and how does it relate to nursing retention and satisfaction?

Shah: I think these are 2 separate things. Wellness programs can exist through human resources to help with folks that are dealing with particular issues. But in my perspective, what would really help is for health systems to focus on things that make nurse retention and nurse satisfaction better. And a lot of those are actually the qualities of magnet hospitals.

There is a magnet program for nursing, and hospitals can apply for magnet status, if they meet certain benchmarks in how their nursing programs at their institutions are run. And these magnet programs tend to have higher retention, higher job satisfaction for their nurses. A lot of these have to do with creating opportunities for nurses to continue to grow in their career and in their fields. This through continuing nursing education, leadership opportunities—just growth. We all need to grow and what we're doing, you know?

They also have policies around nurse staffing, they have continuous quality, and they have a culture around organization and leadership for their nurses. Every floor would have a nurse leader, every shift would have a nurse leader. There's a very well-developed framework for how the nursing communication happens, how hospital-level policy gets down to every single person that works there.

So, creating those really open lines of communication, creating education opportunities, creating leadership opportunities, creating career growth opportunities, are really, really important. And you see, I think, from this survey, what the nurses are describing as reasons why they're leaving or considering to leave their job, are because perhaps those avenues are not being addressed in their workplace.

HCPLive: In relation to COVID-19: Imaginably, a lot of external factors outside of the actual job—especially this year, where this is the first time we've seen a healthcare matter not only this large in scope, but so politicized and discussed—are now driving burnout.

Would you guess that we have we seen such an effect before, in terms of external factors in driving caregiver burnout and stress?

Shah: Yeah, that's such a good question. I think you're right. There's been a lot of politicization of a public health issue where there's nothing political about it. This is a public health issue that we as a country have to come together around. I can't think of anything off the top of my head that has put especially hospital staffing in the center of a political issue in this way.

I imagine the closest thing is probably, in my opinion, the AIDS epidemic, where you might have had hospital staff that might not want to take care of certain patients because of the stigma associated with it. But this is on a much larger and different scale, I would say, then what we have ever previously experienced.

HCPLive: And the shift in discussion surrounding healthcare as a politicized issue, as brought on by COVID-19, is still fairly young. Is there a chance its effect on nurse and caregiver satisfaction and retention could worsen over time?

Shah: It's so challenging, because we already had some pretty stark disparities in terms of health access and care, and I think those are only getting worse and growing. I personally think the issue of nurse burnout and nurse staffing is going to be particularly relevant and very unique to this pandemic, because nurses are predominantly a female workforce. And I think that's quite unique to nurses compared to other healthcare providers even.

This is just me, but I think that women have been disproportionately impacted in terms of what they have to balance. Before a pandemic, 10% of nurses who left their job. Of those, over 30% are saying it's because of burnout. Then in a pandemic, or post-pandemic, I would imagine that that that can't get any better.