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Addressing Burnout Among LTC Staff

November 06, 2019

Chris Caulfield, RN, chief nursing officer at IntelyCare, highlights factors that lead to burnout for nurses, the environment that encourages higher rates of burnout, and what facilities can do to combat burnout.

Podcast Transcript:

Hi, my name is Chris Caulfield, and I'm the cofounder and Chief Nursing Officer of IntelyCare. I'm here to speak about burnout in nursing facilities today. I'm a registered nurse and family nurse practitioner with a background in skilled nursing, long-term acute care, geri-psych, labor relations, and urgent care.

Several years back, I was representing a group of nurses at a local long-term care facility, and our biggest struggle was mandatory overtime and last-minute call-offs.

I was working in Massachusetts at the time, and even though it is illegal in this state to mandate nurses to work overtime it happens.  Nurses don’t want to abandon their patients, and facilities don’t want to leave their floors understaffed but given the circumstances it creates a grey area in staffing - where all of my nurses were staying, and picking up extra hours, just to make sure their patients receive the proper care they deserved when someone doesn’t show up.

As a Nursing Union Leader, I noticed this was causing burnout within my own pool of nurses, and our rate of turnover (nurses leaving our facility) was going through the roof. There was really no good solutions out there that myself and management could utilize to actually help us with staffing, which inspired me to start my own on-demand nursing platform to address the staffing pain point and really combat this issue of nursing burnout

When we talk about burnout - we mean emotional exhaustion. Skilled nursing facilities have the highest rate of nurse burnout in any setting; the burnout rate among nurses in skilled nursing facilities is 37%, 34% in hospitals, and 22% in other settings.

Let's start with the factors that lead to burnout for nurses. There's many of them, but I'll mention some of the big ones. High workload, increasingly higher acuity of patients, little time to really deal with your tasks that are important for patient care, and also the lack of human resources available to staff are all major contributors to burnout.

For long-term care facilities, what is it about that environment that encourages higher rates of burnout? Skilled nursing facilities, more than other settings, rely on overtime and doubles, due to the frequency they are encountering short staffing. This is obviously a big cause of the burnout.

In general, these facilities don't have the HR resources or tools to recruit, engage, and refill shifts like big hospitals do. Many of the facilities that my organization is working at, have three units and there's three nurses working at night time. With a lack of efficient resources, it's really hard to move and flex nurses around in a skilled nursing facility in the way that bigger hospitals can. Ultimately, a lot of times it's that nurse that's working 3:00 to 11:00 and they're having to stay until 7:00 even though that's usually the time they sleep! There's typically not a big pool of staff that the scheduler or director of nursing can call on, and they don't have resources to refill shifts at the last moment.

As I mentioned, another big reason why skilled nursing facilities have a higher burnout is the lack of professional resources and training managers. This is particularly at night time as the supervisors are often just staff nurses that have been promoted to the supervisor role. In this case, the supervisors don't necessarily have the background as management and for these night nurses, these supervisors are actually their managers. Studies also indicate that nurses are 2.5 times more likely to consider quitting when their average workday is 10 hours versus 8 hours. In the skilled nursing facilities when there's lots of mandatory overtime, it's basically creating a vicious cycle of understaffing and increased turnover.

How does high turnover impact patient care? Numerous studies show that when more nurses are burned out, the patient perception of the care decreases, even if the outcomes are the same. Burned out nurses are five times more likely to leave tasks unfinished, including important nursing tasks and interventions that actually have an impact on patient outcomes.

Burned out nurses are more likely to call out of shifts, which make it incredibly difficult for skilled nursing facilities to back-fill that shift. Often, burned out nurses simply leave the profession - which only exacerbates the nursing shortage

What can facilities do to combat burnout?

There's many different interventions and practices that show positive results, I'm just going to mention three today. One is initiate flexible work practices. There's a big push from the ICN (International Council of Nurses) to really promote this practice, and it's allowing nurses to be flexible around their work commitments. That means creating more opportunities for part time work, allowing different start times, finish times, allowing your nurses to switch shifts with other nurses.

Also, in addition to increased flexibility, facilities should always consider allowing temp agencies to come in as needed so that other people can work flexible work practices.

Other interventions that have proven to be effective is the inclusion of additional communication and dementia training.

As nurses and nursing assistants are caring for high-need patients, it becomes very stressful if they're not appropriately trained in the right approaches to de-escalate situations that get out of control.

Lastly, stress relief and management courses can increase nurse mindfulness and decrease nurse stress. Web-based stress relief programs make this practice more accessible.

Because most facilities hardly have the time or resources to bring nurses in to meet with a psychologist, there's now resources out there that you can enroll your nurses into an online, mobile based programs that really works on identifying stress and coaches nurses to deal with it appropriately.

The major concern with starting an intervention is the question of whether staff will positively respond to the interventions to decrease burnout.

Start interventions that are really user centered, you wouldn't to trial out a project and go a whole year to see what is there real issue, and you also wouldn't want to start prioritizing interventions if this isn't really an issue in your facility. My recommendation is to find out what the biggest need and prioritize towards your own staff.

Where do we think that the future of burnout will be in, say, five years?

Skilled nursing facilities need to address their staffing shortcomings head-on - the nursing shortage isn’t going away.  I think SNFs that struggle to adequately staff will need to leverage scheduling software that promotes flexible work environment and practices, and implement a more efficient, technology-enabled shift swapping system, so there is a reduced burden on the scheduling and management staff.

Right now, that's one of the reasons why implementing a more flexible work practice is hard to pull off, because there's a lot of back end work that goes on to actually pull that off. And facilities don’t have time to do that extra work.

Fortunately, now there's more and more software features that are particularly targeted toward hospitals that are now actually working their way down to the skilled nursing facilities that provide self-scheduling and scheduling of your own staff, that also provides mobile apps to your nurses, allowing them to switch.

Also, with that, is some of the on-demand, supplemental staffing companies that are integrating with this internal schedule, to really fill shifts as needed, and when there are callouts.

Some other things that I believe are going to be coming as there's going to be a change in digital training and kind of revolutionary practice of including virtual reality into training.

This will better empower nurses to understand clinical issues and will enable facilities to incorporate stress relief training into their practice.

Another big innovation that I think is coming in the next couple years, is more data analytics from sensor technology that will be implemented. Right now, they're being implemented in bigger hospitals but have yet spread to the post-acute facility side in a big way.

This will allow for the ability to more efficiently prioritize clinical needs and increase the efficiency of the nurse on their job right now, because as we know, nurses in skilled nursing facilities can take on 20 and sometimes 40 patients. It's really hard to be watching all of your patients at the same time. The better utilization of early detection will allow issues to be handled much quicker, and will also allow those issues to be handled in a more efficient manner, That's really my prediction what's going to happen in the future.

Ultimately, if these interventions are implemented, along with access to a greater flexibility in schedule building for nurses, I believe it could help reduce turnover in the skilled nursing space, reduce burnout and improve the nursing experience, as well as improve patient care and outcomes.

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