Sisaket,Thailand,09 April 2019;Medical staff wearing face shield and medical mask for protect coronavirus covid-19 virus in CT scan room,Sisaket province,Thailand,ASIA.

The Future of Acute and Critical Care Nursing

By Sarah A. Delgado

We need to change the future for nurses. Even before the pandemic, nurses suffered high rates of burnout and a disproportionate risk of suicide. But the pandemic could be a tipping point that leads many nurses to change careers, leave their jobs, or retire early.

Moral distress, the consequence of feeling constrained from taking ethical action, was well-documented before the pandemic, particularly among critical care nurses providing end-of-life care. Additional research conducted before 2020 demonstrates that nurses were experiencing post-traumatic stress due to the suffering they witnessed and the demands of their work.

During the pandemic, surges in critically ill patients have led to untenable workloads. The distress of end-of-life care is heightened by restrictions on visitation and increased mortality rates. In addition, shortages of basic personal protective equipment contribute to fear and a sense of betrayal.

While the pre-pandemic state of the nursing profession was concerning, the pandemic creates imminent peril.

In considering the risks of attrition, we must recognize the unique value of acute and critical care nurses. Nurses are vital to the care of hospitalized patients. In fact, the rationale for admitting patients is for the care that nurses provide in collaboration with other health care professionals. Nurses are with patients every hour of every day, monitoring their physiologic status, analyzing complex data, administering lifesaving treatment, and translating information for families.  The foundation of acute care delivery is appropriate nurse staffing and expertise.

Desperate for the unique skill set that an experienced nurse can bring, hospitals have paid top dollar for travel nurses as temporary staff during the pandemic. While the pay is attractive, there are other factors that lead nurses to accept travel positions.  Nurses in permanent positions may not feel valued for their contributions. It is also plausible that acute and critical care nurses accept travel assignments in pursuit of the physical and psychological safety that their current roles do not provide.

The enormity of the COVID crisis has also generated a new appreciation for nurses and the care they provide.

A boost in nursing school applications is a hopeful sign, but the students entering now will not immediately be ready to take the place of experienced nurses retiring or leaving the field. Like many professions, some of what nurses do is learned in school and a lot of what nurses do is learned through experience. Retiring nurses, expanding opportunities in nursing, and advances in health care technology contribute to an ever-widening experience-complexity gap in nursing. This gap means that as the needs of hospitalized patients become increasingly complex, the volume of experience-based knowledge and skills among nurses is in decline.

With these numerous challenges in mind, the following strategies may help improve the future for the nursing workforce:

First, hospital and health system leaders, as well as state and federal policy makers must prioritize the safety of the health care workforce. This means providing adequate personal protective equipment and employing engineering and administrative measures to reduce exposure to infectious disease. Physical safety also means implementing staffing plans that allow time for meal breaks, hydration, and other needs.

Equally important is the psychological safety of the healthcare workforce.  Work environments that stigmatize mental health challenges or castigate those that speak up about ethical concerns are profoundly dangerous. Mental health services that can mitigate the psychological sequelae of COVID-related trauma must be funded and easily accessible. In addition, resources to facilitate ethical reflection can ease moral distress without sacrificing moral sensitivity and help ensure appropriate patient care.

Administrators and clinical leaders can also increase nurse retention, reduce moral distress, and improve patient care by implementing strategies to improve the health of the work environment. The American Association of Critical-Care Nurses offers a framework for such efforts in the Standards for Establishing and Sustaining Healthy Work Environments. Initially written in 2005 and updated in 2016, the six standards may seem like common sense but all are evidence-based and, when implemented, associated with positive change. Other organizations, including the Institute for Health Care Improvement and the National Academy of Medicine, have similarly called for system-level changes to address health care work environments and improve the well-being of the workforce and the patients they serve.

To narrow nursing’s experience-complexity gap, acute care facilities can initiate flexible staffing models that retain experienced nurses and offer rotations to expand newer nurses’ professional development. Telehealth and team staffing models are other strategies that were employed successfully during the pandemic to distribute nursing expertise across a wider pool of patients. Working in teams gives less-experienced nurses access to the knowledge and skills of more-experienced nurses.

Finally, at all levels of decision-making related to the delivery of health care, nurses must have a voice. Every group, from national task forces, to state regulatory bodies, to individual hospital committees, must include nursing.  The benefits of such inclusion are twofold. First, nursing expertise is unique to our profession; no other profession can represent what we do and how we do it. The second benefit is meaningful recognition. While applause is heartfelt and free food is a genuine act of kindness, bringing nurses into decision-making groups is empowering.

Whatever the future holds for health care, nurses — the largest group of health care professionals and the most trusted profession — will be essential to its delivery and a lifeline during patients’ most vulnerable moments. Nurses find immense satisfaction in human connection with patients; it is other aspects of their job that generate distress and burnout. Prioritizing nurse well-being, improving health care work environments, and hearing nurses’ voices are steps toward a future of optimal patient care.

Sarah A. Delgado, MSN RN ACNP is a Clinical Practice Specialist for the American Association of Critical-Care Nurses.

This post is part of our digital symposium, In Their Own Words: COVID-19 and the Future of the Health Care Workforce

The Petrie-Flom Center Staff

The Petrie-Flom Center staff often posts updates, announcements, and guests posts on behalf of others.

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