Vital Views

Renowned nurse educator and scientist Dr. Christopher Friese joins the show to look at current nursing labor concerns from a nationwide level. He explains why nurse-to-patient ratios have become more imbalanced; how shortages are connected to economic highs and lows; and what nurses need to do to remain strong advocates for their patients and the profession.

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Part 2:

Recorded August 3rd, 2022

Creators & Guests

Joseph Gaccione
Host, Writer, Producer
Christopher Friese
Elizabeth Tone Hosmer Professor of Nursing, Health Management and Policy Director for the Center for Improving Patient and Population Health

What is Vital Views?

Vital Views is a weekly podcast created by UNLV School of Nursing to discuss health care from a Rebel Nursing perspective. We share stories and expert information on both nursing-specific and broader healthcare topics to bring attention to the health trends and issues that affect us. New episodes every Tuesday.

Feedback? Questions? Episode Ideas? Email

Joe Gaccione 0:01
Hello, and welcome to Vital Views, podcast for UNLV School of Nursing. I'm Joseph Gaccione, Communications Director for the School of Nursing. Nursing shortages have been recognized in Clark County and other parts of the country. And while COVID-19 has worsened the conditions to make nurses leave, shortages are not just pandemic-based. They have existed for a multitude of reasons and eventually resolved themselves depending on the scope, but more solutions are necessary to help minimize a labor problem that impacts the entire healthcare system. For a series of episodes, we'll explore different aspects of nursing shortages, from current conditions to previous shortages, the causes, the impacts, and what are the most optimal solutions to either avoid or minimize gaps in nursing labor. We have a very special guest for today's episode. Here in the booth with me is Dr. Christopher Friese, Elizabeth Tone Hosmer Professor of Nursing from the University of Michigan School of Nursing. His background and expertise are extensive. Among his roles, he's also the Director for the Center for Improving Patient and Population Health and Associate Director for Cancer Control and Population Sciences at the Rogel Cancer Center. He was elected to the National Academy of Medicine in 2020 and last year, President Joe Biden appointed him to the National Cancer Advisory Board, which advises on National Cancer Research Policy. Dr. Friese is in town this week speaking to our new graduate students at our 2022 Silvestri Lecture and he's graciously sharing some time to chat with us. Dr. Friese, thanks for coming by.

Christopher Friese 1:22
It's great to be with you.

Joe Gaccione 1:23
Let's start with an open-ended question. Compared to previous nursing shortages, how do you think our current situation compares? Is there even a close precedent?

Christopher Friese 1:31
When I think about the current situation in 2022, what really harkens back, for me, is 25 years ago, when I started in nursing in the 1990s. There was an acute nursing shortage right around the year 2000. And the causes were slightly different. We didn't have a global pandemic, we didn't have some of these other pressing matters, but what we did have that was shared was really a disconnect between management and frontline clinicians. And so that is very similar. And the good news is that's fixable. What we lay on top of that, is two years of the COVID pandemic, of increasingly complicated patients seeking care, and also vacancies from nurses who are having their own challenges in their household, staying well themselves, or family members and friends. So that adds a unique layer to this workforce crisis and it remains to be seen exactly how we get out of this.

Joe Gaccione 2:34
In previous episodes, we've talked about mental health and how that's a leading factor in nurses leaving the field, not necessarily the only reason, but a big factor. We've also talked about how burnout is both a cause and it's an effect of shortages. Mental health is important across all professions and communities, but nurses go through so many different high stress situations and that's just in non-pandemic times. How can hospitals maintain or enhance their work environments to accommodate better nursing performance and wellbeing?

Christopher Friese 3:01
So, it's a good question and I think we need sort of two levels of strategy. The first is that leaders of hospitals really need to take a careful look at what they're asking their nurses to do on a daily basis. Number one, they need to listen really carefully to what the nurses are telling them in terms of what the bottlenecks are in their system and they need to work in a very focused manner on addressing those bottlenecks because if we don't fix the underlying system, the underlying structure of hospital care right now that is not working, more and more nurses are going to leave. That's a constant throughout our decades of experience of nursing shortages. Every time we've had a big nursing shortage, we've had to change the way we deliver care. So, that's hard work but doable work and we know how to do that. That's number one. The second thing that's in a way is a mixed blessing is we have this increased recognition of the needs of individual nurses to both assess and address their mental health. I'm excited about some of the legislation that has been passed in the federal government, the Breen Act that will provide some research grants to institutions to both assess and intervene, where we see nurses having trouble and other healthcare professionals. So that's a really welcomed step. It's one of the first steps I've seen where we've openly acknowledged that our healthcare professionals need mental healthcare. And the take-home message I have from that is for any nurse who's practicing, we would never let a patient with diabetes just go without their insulin, without their insulin medication or their blood sugar being checked. It's, it's time for every individual nurse to make sure they're doing okay from a mental health perspective and if they're not, seek professional help and make sure they're getting the help they need, whether they stay in their job or not. We care about you as an individual and, and I really appreciate the increased recognition of that issue right now. I think it's really critical.

Joe Gaccione 4:58
Is there a way for hospitals, this might sound kind of redundant, is there a way for hospitals to better measure a nurse's wellbeing day in, day out, weekly? Is there a point of being too intrusive in someone's personal life or is there really no limit to how often you should check in?

Christopher Friese 5:14
I don't think we have an exact answer yet. I think some of the research grants that will be funded through the Breen Act will help us understand that this is still a little bit of new territory for us. But I think one thing would be don't just do it one time, don't do a one-time assessment, number one. Number two is probably outsource it and not have it directly linked to your, to your leadership team in your hospital. What I have heard over 20 years of working with nurses is they're happy to tell us their honest truth, they don't want their employer to know directly. So, there are employee assistance programs or other kinds of programs, third party groups who can do accurate assessments of mental health conditions and then provide the referrals in a way that the employer doesn't know who is getting help or not. So, if we can eliminate that barrier, I think we'll actually have more nurses truthfully tell us how they're doing and we can actually get them the appropriate support they need. So, we don't know exactly how often we need to do this, I think that'll be borne out in the research, but what we do know is we need to get started, and there are groups that can do this for health systems and I encourage them, honestly, to move it outside of their formal health care system, so that an employee feel safe and comfortable talking about these issues.

Joe Gaccione 6:27
Another issue that's come up in past conversations about this has patient-to-nurse ratios. And obviously, you can't talk about it on like, a Nevada state level, but in a bigger, like a nationwide level, do you think there should be changes to patient-to-nurse ratios?

Christopher Friese 6:41
So, nurses have told us for about 10 years now consistently, even longer if you go farther back, but for certainly, we have seen a deterioration in nurse staffing across the United States. We see it in certain pockets, it's even worse than other places, but what nurses are continually telling us is they're caring for too many patients in their work environment. And what we, what could happen, very quickly, is if hospital leaders recognize this problem and they put the structures in place to make sure that nurses do not exceed patient lows that we know are safe and we define that in various areas, if you're an ER nurse, or an ICU nurse, or a medical surgical nurse. We know what those are, they're published, we've had that evidence for two decades. It's time to enact that work. We don't need a law to do it, the hospitals can do it tomorrow. The hospitals have been reluctant to do so because it's going to cost them money, but what I would say is the amount of money they're spending now on agency nurses over time and adverse patient events from poor staffing are likely a much larger pot of money than if they actually got their nurse staffing ratios to a place that we know is safe. So, the analogy I use here is airlines. If you fly a 757, you have a set number of flight attendants and a set number of pilots and that's sacrosanct. We don't have that level of protection for healthcare and the stakes are much higher for a mistake in healthcare. So, why we wouldn't enact this evidence base at this point is beyond me. I think it's past time and I think that's why we're seeing the shortages that we're seeing, is nurses realize they can no longer do this amount of work that cannot care for the exceeding number of patients that they're being asked to care for.

Joe Gaccione 8:27
So, the hospitals think that it would be more expensive to hire more nurses than it would be to do what they're currently doing. It would be more expensive for them to just pay extra employees, but they’re, aren't they're also paying like, travel nurses, for example? Travel nurses are coming in and they get paid a lot of money.

Christopher Friese 8:44
Right. You know, I'll leave it to the economist to do the full mathematical analysis, but to me, a healthy and safe hospital that can care for the patients that they are assigned to care for is paramount. And what we have right now is a very fragmented system, we're plugging holes, and we haven't, but we're looking up at the ceiling, there's a gaping hole in the ceiling. So, we need to fix the ceiling, we need to fix the roof. And the way we fix the roof is making sure that we have a basic level of nursing care available to all patients at a hospital. Right now, we don't have that guarantee and what is happening is hospitals are plugging holes with agency nurses, with mandatory overtime, and these other policies that we know leave nurses to leave their jobs and put patients at risk. So, it's, it's a mathematical question and I know it's a difficult one, but we need to be we need to begin to move the tide to recognize that we can't just add more patients to a nurse's workload. That's an unsafe recipe and we've relied on that for far too long

Joe Gaccione 9:46
Out here, Governor Steve Sisolak, Governor for Nevada, had advocated for nursing apprentices, students to come out of nursing school to help kind of fill those gaps as best they could and we saw some success from UNLV. I think we had about 20 for spring, I don't know yet the numbers for summer. Over at University of Michigan, did you have any student apprentices go in?

Christopher Friese 10:04
To my knowledge, we had, we were ready to go with a proposal for that and our COVID surge eased to the point where the systems did not request that level of care. I think the apprenticeship model is interesting. What I'm, what I'm often saying to nurses now is making sure that anything that we do like that, any kind of change to the way we deliver care, that we are evaluating patient outcomes. So, we have a term we call “failure to rescue,” that means you have a death after a preventable complication. So, we want to make sure that any changes we have to the system, we're tracking outcomes as well to make sure we're not making anything worse and that we're keeping patients safe. So, I think it's exciting to test some models, we want to make sure we do it carefully, and we want to make sure that the entire team, including physicians and pharmacists, know that we're changing the way we're delivering nursing care, so that they're not expecting the same dynamic that they currently have, number one, and number two, make sure we follow outcomes over time to make sure that patients are safe, nurses are satisfied, the apprentices have a good experience.

Joe Gaccione 11:11
We touched on the economics before, and you were a coauthor in a recently published article in the New England Journal of Medicine, and in that article, you talked about how shortages can run parallel to economic highs and lows. Can you talk a little bit about that correlation and where do you see the trend going in our near future, potentially?

Christopher Friese 11:27
So, this is an interesting paradox. What we've learned over the years from nurses is that nurses leave their jobs when the overall economy is good, because on average in the United States, nurses work in two-income households and when the economy is good, their spouse or partner tends to do better and therefore, the nurse can reduce, either reduce their hours or leave the bedside for a period of time or do something else for a little bit and then when the economy worsens, and, again, the spouse might be threatened with job issues or wages, the nurse can come back in, the flexibility of nursing is really great. So, what we are a little bit worried about, we don't really know because we're still in this very strange economic situation at a national level with higher prices, but employment is up and wages are up and historically, that would mean that nurses are likely to step away from clinical care when the overall economy, employment, and wages are up. With prices high, it remains to be seen. So, will nurses stay around because they're paying more for all their daily expenses or not? We don't know, we haven't been in this situation before. But, it's a cautionary tale that nurses may not stay in this moment as COVID eases, or we hope it eases, nurses may decide to leave for, because of their family economics, their family economics may be doing better and they may not feel the need to stay working full-time, stay in their work environment, they may want to reduce their hours.

Joe Gaccione 12:56
One word of caution, I've spoken with to, within the past year, several CNOs out here in the valley and when it comes to students graduating, they're trying to look for jobs. One area of caution they stress is don't assume that because there are shortages, that you'll just automatically get hired, there still is a process in place, and you still need to do your best because there's no guarantee just because a hospital might need nurses, doesn't mean they'll hire anybody.

Christopher Friese 13:21
Absolutely right. And so, the message for, for current students or folks who are thinking about nursing is we still need everyone trained to the best of their abilities, staying focused, doing all the things that would put you in a good position. I was, I was, interesting, you know, particularly people who want to do certain specialties and things, we can't always expect they're going to be able to go right into the emergency department or right into the operating room or right into the ICU right away. I think we need to be realistic, we want people to start on a good foundation and just because we're having these acute shortages, doesn't mean you have your pick of the litter, you still need to be competitive, you still need to make a good case. And I always recommend nurses, particularly graduates, look for hospitals that have what we call nurse residency programs, where they still have a formal, fairly longer-term orientation project process to get nurses up to speed and comfortable in their environment. So, don't just think you can run in there tomorrow and be ready to go. You still need time to orient, to get oriented to your environment, get up to speed, be ready to practice.

Joe Gaccione 14:28
I want to pivot for a second, to be a little more cognizant of your time. We mentioned before you're in town to speak to our incoming graduate students. Your topic is the best hope for patients and communities, nursing science challenges and opportunities. Can you give us a little spoiler alert about what that message is going to be to the students?

Christopher Friese 14:45
Well, despite the challenges we've just talked about for a few minutes here, I'm still confident that 25 years later, I'm celebrating my 25th anniversary as a nurse, nursing really is the best hope for patients and communities, the families that we serve. There's a tremendous opportunity for nursing and I still highly recommend people join the field, they look to apply, they, they stay in the field, because the amount of good that we can do both as an individual and as a collective body is tremendous. We have some work to do to shore up our work environments, we need to make sure our patients and communities are safe, but we've done that work before, and we can do it again. And so, we need all hands on deck. We need people to pursue graduate programs. We need people to stay at the bedside. Wherever they're most comfortable practicing out in the community. It's never been a better time to be a nurse and we need your voice and we need your skills, we need your advocacy for a better healthy future for our communities.

Joe Gaccione 15:42
Well, that is all I have. Dr. Friese, thank you for stopping in.

Christopher Friese 15:45
Great to be with you. Thanks.

Joe Gaccione 15:46
Good luck with your presentation on campus and everyone out there, thanks for listening and have a great day.

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