Dr. Jean Moore of the University at Albany's Center for Health Workforce Studies (CHWS) is the guest on this episode of The Engagement Ring. Dr. Moore discusses a recent CHWS study, supported by the Mother Cabrini Health Foundation, that examined the problem of the nursing shortage in New York State and identified promising strategies for improving the recruitment and retention of patient care RNs, with a special emphasis on safety-net hospitals.
Center for Health Workforce Studies
Understanding and Responding to Registered Nursing Shortages in Acute Care Hospitals in New York.pdf
Mother Cabrini Health Foundation
Q&A with Jean Moore, Director of UAlbany’s Center for Health Workforce Studies
University at Albany School of Public Health
Department of Health Policy, Management, and Behavior, UAlbany School of Public Health
Additional information on Dr. Moore’s research at ResearchGate
SPH Study: Health Workforce Shortages Persist in New York State
Dental Hygiene Scope of Practice: Why It Matters (Webinar)
University at Albany Nursing Programs
The Engagement Ring, Episode 23: Examining the Nursing Shortage in New York State – Causes, Symptoms and Possible Cures
[Lively, upbeat theme music plays as program host Mary Hunt introduces the program and plays excerpts from the program.]
ANNOUNCER/MARY HUNT:
Welcome to The Engagement Ring, your connection to an ever-widening network of higher education professionals, scholars, and community partners, working to make the world a better place. I'm Mary Hunt. Today on the podcast…
DR. JEAN MOORE:
It was fairly pervasive. I think that hospitals across the state were experiencing great difficulty both recruiting registered nurses and retaining them.
ANNOUNCER/MARY HUNT:
By the year 2030, New York State is projected to face a shortage of almost 40,000 nurses. I'll talk with Dr Jean Moore, director of the University at Albany’s Center for Health Workforce studies about a recent study the center conducted to better understand the factors contributing to New York's nursing shortage and identify promising strategies for improving the recruitment and retention of patient care RNs.
DR. JEAN MOORE:
There's no single strategy that emerged as a silver bullet. There were differences in approaches based on geography, hospital size, available resources… I also think there are probably some wonderful opportunities that we have available to us to share best practices.
ANNOUNCER/MARY HUNT:
Here's my conversation with Dr Jean Moore…
MARY HUNT:
Welcome to the podcast, Jean.
DR. JEAN MOORE:
Thank you.
MARY HUNT:
It's so nice to have you. I have heard about your work and research at UAlbany for a long time, and my colleagues have spoken so highly of it. I know you're studying important topics. So, it's really a pleasure to have you here today. I have heard about nursing shortages for years. It seems like I'm always reading an article about it or hearing that we're having a health care workforce shortage. But from your report it sounds like maybe this time there are some different factors at play, or it's a different situation this time, and there might be some very complicated, complex issues that are impacting the shortage. How would you characterize the shortage? Would you say we're in a crisis stage? Would you say this is just a phase that we're working through or…
DR. JEAN MOORE:
What I'd like to do is just tell you about a research study we conducted recently where we actually took a much closer look at nursing shortages in acute care hospitals. So, this study was funded by the Cabrini Health Foundation, and it was what we would call a mixed methods study. So, the qualitative piece created an opportunity for us to conduct key informant interviews, and our primary targets were hospital chief nursing officers, hospital HR departments. But we also had a quantitative component because I think it's important to take available data and help you kind of better understand what you're looking at, what the issues are. And actually, at the point we began this study a rather exciting new data source became available. So, the state requires mandatory reporting for healthcare professionals at time of re-registration. So, if you're a licensed nurse or physical therapist, or whatever, you need to provide information to the state when they ask for it. So, there haven't been a lot of resources to implement. But we decided that, and we meaning working collaboratively with DOH and State Health Department and State Education Department, that we wanted to launch a survey, do a re-registration survey for registered nurses. So, we put a survey together, and one of the things we decided to include, so the survey went into the field in 2022 so we're, you know, just kind of coming out of the, you know, the more severe pandemic situation. So, we decided to ask about burnout and ask about, and there are a lot of different ways you could measure it, but we included some behaviors that would suggest professional burnout. But we also asked about other things like demographics, education, practice characteristics, future plans… so anyway, we were delighted to have access to these data because we felt like it could really help us paint a much clearer picture of what we know about nurses in New York. So again, a qualitative piece with key informant interviews and a quantitative piece where we analyzed available workforce data.
MARY HUNT:
Let me, let me ask you. Let me ask you this before you get into the data specifically and what you found in the report… the report was prompted because of the nursing shortage in New York State and the challenges with recruitment and retention of nurses, but how widespread is that in New York State?
DR. JEAN MOORE:
It was fairly pervasive. I think that hospitals across the state were experiencing great difficulty both recruiting registered nurses and retaining them. And if you like, I can certainly talk you through, you know, what were some of the things that contributed to recruitment problems and retention problems? And the other thing I can tell you is what hospitals were doing about it. Because, you know, when you talk about the you know, well, did it change over time, I think hospitals began to recognize that there were things they needed to do if they wanted to make sure that the supply of nurses they had was adequate to fill the positions they needed. So, the purpose of the study was to first profile the state's RN workforce, using available data, and again, learning enough from key informant interviews to know what we wanted to look at to identify key factors contributing to recruitment and retention challenges in hospitals, and to describe the most promising strategies that providers were using to address these challenges. So, it was really kind of looking at kind of a broad swath of okay, we start with a shortage, what do we know about what's contributing to that, and what are we doing about it? And how's it working? Periodic shortages of RNs in the country are not new. It happens, and previous shortages were attributed to a lot of different things, including an aging registered nurse workforce, decline in interest in nursing careers, changes in the healthcare delivery system. Back in 2000 there was a move to managed care that was thought to have had some substantial impacts on, oh, hospital bed use, patient acuity, etc. So anyway, the approaches used to address the shortage, which are kind of interesting. One was reaching out to new candidate pools. If less women were interested in becoming nurses, you know, as a career path, many of the nursing schools look to attract second-career, people who look were looking for second-career, men. They looked at career ladders and created opportunities for licensed practical nurses to enter a program that would help them become RNs after they completed. So, there was a lot of thought into, okay, we can't just depend on who we used to. We're going to try something different. The other thing that that happened was there was a national campaign promoting the value of nursing careers. I think it was Robert Wood Johnson Foundation partnered with another group. And, you know, there were a lot of kind of public service messages out there saying, become a nurse, or, you know, nurses make a difference and whatever, and broadcasted widely. So anyway, shortages from the past can be attributed to a lot of different things and once you understand why then you can kind of appreciate the approaches or interventions that were used.
MARY HUNT:
What's different about the shortage today?
DR. JEAN MOORE:
The current RN shortage was clearly exacerbated by the Covid pandemic. So, first of all, you saw a lot of patient care RNs leave their jobs, so the existing workforce turned over and left for a variety of reasons. Some contracted Covid. Some were afraid of contracting Covid. Some refused the vaccine mandate. Some found better jobs, and one of those better jobs was to become a traveler. Traveling nurses were a real hot commodity for a while, and the pay was quite high compared to what a staff nurse might earn. Some left for family obligations, particularly childcare. When you think about what was going on during Covid that is certainly understandable. And still others just retired. You know, we have a whole cohort of baby boomer RNs who are in the process of leaving, and I'm sure that Covid facilitated the exits to some degree. The thing that we probably say less about but is just as important is impacts on the nursing education pipeline. So, you know, like everyone else during Covid, nursing education moved to virtual classroom learning. But one of the things that was a bit more problematic, clinical rotations were paused. Health care providers said, we can't take students, um, we're we've got a crisis on our hands, and we're just not able to accommodate. So that meant that the students in the pipeline were in jeopardy of not graduating on time because they couldn't meet their clinical obligations. Many, many schools turn to simulation to help students complete their requirements and graduate on time, so most students actually completed their training in the timeframes that were expected. But there was a difference between the experience of working with patients in hospitals and learning skills through simulation.
MARY HUNT:
Did they not feel as prepared?
DR. JEAN MOORE:
You hit the nail on the head. I'll say more about that. But the one thing I want to point out is even when the pandemic was easing, shortages persisted. So, it's like, you know, I think everybody thought, oh, great, the pandemic is over, we can get back to work. And it didn't turn out that way. So, what contributed to the persistence of the recruitment and retention problem? So, this is something we heard from key informants, but also that was confirmed in a literature review we conducted. So, one was work environment… that acute care hospitals became a very, very challenging work environment place to be. And some units actually, some, some units were… positions were a lot harder to fill than others… ER, CCU. We also heard Med Surg, night shifts were very difficult. Use of travelers. Many hospitals used travelers because they had to. They had to staff their units, but it was kind of a double-edged sword. If a staff nurse is working alongside a traveler, you're both doing the same things, and she’s earning twice as mujch as you, how does that work? So, I think that there is certainly something very, very demoralizing about that, to feel like you're not valued. I think that there was a lot of burnout. A lot of the nurses who were on those units experienced burnout. There was just a lot of stress in providing patient care, but also higher acuity levels, very sick people, many of them delayed care during Covid, and then showed up looking for care once the pandemic died down, um, staffing shortages. And then another thing we heard a lot about was violence, that there was much more violence happening. Oftentimes, patients, families were disinhibited and, you know, and again, you know, thinking about it's an acute care hospital, someone in the family is seriously ill. They’re short-staffed and clearly the nurse could be a clearly be a target of that anger. But many of the facilities we talked to were very, very troubled by it and actually put together some strategies to try to address it. But the issue of patient violence, I think, has kind of risen in terms of how much of it is going on, and again, hospitals doing their best to try to control it. But there were other things going on that contributed to the current shortage. So, we covered work environment. Your point earlier about new RN grads less prepared for transition to practice. The lack of patient experience during training took its toll, and there were very challenging situations that these new RNs weren't well equipped to deal with. And the other thing I probably want to point out here is that when I talked about, you know, earlier the attrition from patient care that you know, a lot of nurses left. A lot of them were the experienced nurses. A lot of them were the nurses who could become the mentors for the new grads, and there weren't as many of them. So that proved challenging. The other thing we heard is generational shift, that younger generation folks are different than older generations. They have different expectations. They're a bit less mission driven. They're great at technology. I mean, they have, you know, they were working their iPhones when they were four years old. So, much more concerned with work life, balance, flexibility, hybrid work models. And the other issue that that I think we are probably going to need to come to terms with is that they may be less invested in sticking around in the long term, but just want to go try different things. You were looking at nurses who had entirely different perspectives than what you were used to.
MARY HUNT:
That really struck me because in my lifetime, I think of nurses… I don't think of that as one of the types of careers you just try out. That feels like that is a calling or a mission. And it doesn't feel like I'll be a nurse for a couple years…
DR. JEAN MOORE:
No, no, no. I don't think they're saying I'll do it for a couple years. Opportunities in nursing are enormous. You can do a lot of different things -- research, you can teach you can, you know, work for insurers, you can be involved in some form of patient care, but maybe not acute care. So, it's not like nurses are saying, “Okay, I'm done. I'm not going to be a nurse anymore.” I think it was just, “I'm going to try something different.” Because, you know, again, I feel like part of their perspective on this is, well, I'll get some experience here, then I'll go somewhere else and do something else.
MARY HUNT:
Well, that's interesting. I think that makes a lot of sense. And I think that's the thing about nursing. It has really expanded the opportunities, and the education has given rise to new opportunities.
DR. JEAN MOORE:
Right. And again, when we think back on okay, it's tough being in patient care and acute care, and here are these other opportunities, and as you get more experience, opportunities can really open up for nurses looking for a change.
MARY HUNT:
One of the interesting things related to that generational piece that you mentioned in the report was that the younger nurses were burning out faster than the veteran the nurses, the nurses who had been in the profession longer, which kind of didn't make sense to me.
DR. JEAN MOORE:
I will tell you, one of my theories on this is that you know, so, first of all, patient care RNs in hospitals were the ones who reported the highest level of burnout based on the questions we asked. One of our suspicions is that when those older nurses left the ones who stuck around were kind of better adapted to the circumstances, whereas the younger nurses who just came in didn't get the kind of patient care experience that could have been useful for them as they transitioned to practice. So, at some level I'm not really surprised because I think that some of that turnover, some of that attrition of older RNs, help us better understand higher levels of burnout for the younger RNs.
MARY HUNT:
Did you find differences in the challenges upstate versus downstate or rural versus urban hospitals?
DR. JEAN MOORE:
We didn’t see urban-rural differences, but interestingly, upstate RNs showed higher levels of burnout than downstate.
MARY HUNT:
That is surprising.
DR. JEAN MOORE:
That’s something that we intend to take a closer look at because that's somewhat intriguing, but I think that there may be a number of contributing factors, so we're going to take a look. So, we said to the key informants we interviewed, what were some of the things you were doing to recruit nurses? What were your strategies? So, top of the list, educational assistance, either offering scholarships, tuition assistance, anything they could do to engage people to come work there and take advantage of educational opportunities. Another one was something called nurse residencies. Nurse residencies created opportunities for new RNs to acclimate to acute care and get oriented to the units they were going to be working on. So, a lot of hospitals had nurse residencies for specific units, like ER, ICU, CCU, OR, but others just offered it across the board. And again, one of the biggest limiters for that was having the preceptors you needed to be able to provide residencies.
MARY HUNT:
And preceptors being?
DR. JEAN MOORE:
Older nurses. The older nurses who were part of the hospital. So again, once that those nurses turned over or left and you're dealing with a smaller cohort, it was much more challenging. But most if not all of the hospitals we talked to were providing residencies, and like I say, some were, you know, for specific units where the positions were hard to fill, where others were across the board, another thing that they offered were summer student nurse externships. So, they would offer a nursing student to come spend their summer time off working in that hospital, not as a nurse, but as a, you know, nurse aide, whatever, but it gave them a chance to get to know the students and to provide some mentoring as available, but also to get them to think about coming to work there once they completed training. And another strategy that is interesting that ties to this is that some hospitals talked about their experienced nurses serving as adjunct faculty to nearby nursing programs, and they said that was a great way to find students to recruit to come work after they completed training.
MARY HUNT:
In your research, you indicated that a number of these hospals, or what were referred to as safety net hospitals. What does that mean?
DR. JEAN MOORE:
Safety net hospitals serve a higher percentage of Medicaid patients. So, you know, I think the premise is that they might be a bit less resourced, and we were actually, as part of the study, asked to take a closer look at that. But honestly, the issues were the issues, regardless of whether you were safety net or not. They might have had some fewer resources available to address the problems, but I think that everybody was pretty much on the same page around what recruitment strategies they used and what retention strategies they used. So again, I think that there could be some resource limitations, but I think everybody was pretty much in the same boat and dealing with very similar issues. As part of the retention strategies, at the top of the list was improving workplace culture. I think people recognized the need to engage the nursing workforce, to be more supportive to patient care staff. Many of them achieved what's known as magnet status, and it's a program that you know kind of helps you build a culture of engagement and involvement. That's kind of a pricey one. It's certainly not, well, it takes some resources to achieve magnet status. But there was another program called Pathways to Excellence that accomplished similar things and didn't require as many resources. But the concept of improving workplace culture was something we heard time and again. And as part of this, you know, leadership training, succession planning, getting the people who were there, kind of preparing them for the future, engaging them. Preceptor training, you know, again, every hospital we spoke to really needed to develop preceptors to be able to move forward with their current cohort of staff nurses, burnout reduction strategies, including employee assistance programs, wellness teams, tranquility rooms. I mean, we just heard a whole bunch of different strategies that were being used and a lot of times we heard that the plan was informed by talking to the staff and saying, “What would help you right now?”
MARY HUNT:
Jean, your background makes you particularly qualified to study this topic. You have a bachelor's in nursing, two masters, one in psychiatric and mental health nursing, and another in nursing education, maternal and child health, and a PhD in social, behavioral and community health.
DR. JEAN MOORE:
Actually, it's a D-R-P-H, Doctor of Public Health.
MARY HUNT:
D-R-P-H… What inspired first your interest in the nursing field and in public health, and does having such a practical and clinical knowledge of the field… does that hinder you or help you as a researcher in the topic?
DR. JEAN MOORE:
Interesting question.
MARY HUNT:
Does it make it hard to be objective in your research?
DR. JEAN MOORE:
Sometimes I feel like I know enough to get myself in trouble.
[Laughter]
DR. JEAN MOORE:
But you know, I will tell you that at the time that I studied to be a nurse, worked as a nurse, it was a totally different circumstance. I think that times have changed so dramatically, but the one thing I will say is that once I kind of got bitten by the research bug, there was no turning back, and I realized how much I could do by studying workforce and informing policies, programs, etc. My clinical background does help, I kind of understanding what, what patient care RNs struggle with face. I mean, I certainly have a better understanding of that. But again, I would have to say that that in combination with research, really helped me become effective, more effective at what I do.
MARY HUNT:
And what questions did you uncover for the next study? So where to now? If you could do the sequel, could do the next study, what would you want to look into?
DR. JEAN MOORE:
Well, first of all, let me just say that I think there's a lot more we could do, although, you know, one of the things I pointed out is that, you know, periodic nursing shortages, strategies to address those shortages… to what extent are we evaluating them to, you know, and, and I think what happens is that they're probably terrific in the short term, that they actually help kind of move the needle, so we say, “Oh, great, we're done.” And then we get surprised by the next shortage. So, I feel like there's a tremendous need to evaluate the effectiveness of some of the recruitment and retention strategies in the long term that you know, we can't just say, “Okay, we did it, it worked. We're done.” I think it's we did it, it worked, we need to continue monitoring. We need to make sure that what we've put in place is actually working in the longer term. So, there's that. The other thing I will tell you is that we have plans to do a much more thorough analysis of the RN re-registration survey data to take a closer look at a lot of the issues I told you about. So, I feel like there are a number of different directions we plan to go in. We also do an annual survey. We call it our Recruitment and Retention Provider Survey. So, we survey hospitals, long term care providers, home care, ambulatory care, and have a very short survey and ask some fairly basic questions like, “Who are you having trouble recruiting? Who are you having trouble retaining?” And I think it was 2022 when we asked that in 2022 at the top of the list across all the different settings, RN, LPN. So, I think that that was our indication that, wow, this is pretty bad and it's quite pervasive. But I again, as I mentioned to you earlier, I think that there have been some improvements and some of those improvements can be attributed to provider strategies to do a better job of recruiting RNs and then retaining them and making sure that they do everything they can to improve workplace culture, so the nurses feel engaged, safe as they as they do their work. So again, I feel like we've, you know, we've come a long way. And you know, let me say that, you know, there's no single strategy that emerged as a silver bullet. I can't point to one thing and say, gee, if everybody did this… you know, there were differences in approaches based on geography, hospital size, available resources. I also think there are probably some wonderful opportunities that we have available to us to share best practices and understand who's doing what, how is it working, and can it be adapted for others? And you know, so when we said to people, so you know, where are you headed? What are you going to continue doing? Again, the three that really we heard again and again: improving the work environment, as I mentioned, educational assistance to promote better educational attainment, and then workforce development, whether that be residencies, whether leadership training, clinical skill training. So again, I feel like we learned a lot about what providers are doing, and it appears to be having some impacts. I don't think we're out of the woods yet, but we're certainly on a better path than we were two years ago.
MARY HUNT:
Can you please come back and tell us more after the next study or I know you do at the center, you do a number of studies on various workforce issues in the healthcare industry. So, we'd love to hear more.
DR JEAN MOORE:
And Mary, there's another, there's another… I don't know if I sent this to you or not, but we've done some very in-depth work on, believe it or not, dental hygiene scope of practice. States have the capacity to define what health professionals can and can't do in their states, and by and large, for some professions it really doesn't differ very much from one state to the next. Dental hygiene, the variability is incredible. There are states that have very, very restrictive scopes of practice. Other states have broad scopes of practice. And you know, we've done research where we actually looked at, okay, what do states allow. What don't they allow? Put it all together. But then we said, does that matter? Does letting dental hygienists do more actually matter? And the short answer is, yeah, it does. It actually does. States where dental hygienists are allowed to do more have better oral health outcomes than states that don't do that.
MARY HUNT:
You just teased the next podcast, Jean, so you have to come back.
[Laughter]
MARY HUNT:
You have to come back and talk about that.
DR. JEAN MOORE:
There's a webinar that we just did that I think got posted. If I can pull it up, I'll send it to you.
MARY HUNT:
Send it to me. I will, for those listening who are interested in learning more, I will make sure I post these resources and share them because there's lots of great work coming out of the center, and Jean will come back, so we'll talk again more. Thank you, Jean. It's really been a pleasure. Thanks for your important work, and best of luck with your work.
DR. JEAN MOORE:
Oh, very good. And if you have any further questions, feel free to let me know.
MARY HUNT:
Will do. Dr Jean Moore, thanks for being my guest today.
DR. JEAN MOORE:
Take care. Bye.
ANNOUNCER/MARY HUNT:
Dr Jean Moore is a research assistant professor in the Department of Health Policy, Management and Behavior, and serves as the director of the Center for Health Workforce studies at the School of Public Health. Dr Moore has extensively studied health workforce, supply, demand and distribution, and more recently investigated pandemic impacts on the health workforce. She has also studied health professions regulation and its impact on access to care. Established in 1996 the Center for Health Workforce studies conducts research to support and promote health workforce planning and policymaking at local, state and national levels. It operates two of only nine federally funded health workforce research centers in the US. For additional information about Dr Moore's work, the Center for Health Workforce studies, and resources associated with today's podcast, visit The Engagement Ring online at the dash engagement dash ring dot simplecast dot com. The Engagement Ring is produced by the University at Albany's Office for Public Engagement. If you have questions or comments or want to share an idea for an upcoming podcast, email us at UAlbany O P E at Albany dot E D U.
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