From Health Care Workforce Recuperation to Regeneration … –

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The changes needed in core competencies and culture setting at both educational and health care institutions to prevent burnout and job vacancies.
The Executive Vice Dean and Vice Dean for Education at the UCSF School of Medicine and the Assistant Professor at Harvard T.H. Chan School of Public Health discuss the health care workforce crisis from the perspectives of preparing medical students and setting expectations of new employees in the workforce, and what it means for medical and educational institutions to shift from a mindset of recuperation to regeneration in addressing job vacancies and burnout. In shaping a successful health care workforce of the future, educators must break from the mold of legacy thinking and consider the workforce as a whole, not just individuals, teaching new skills that prepare graduates to help solve the unsolved problems in health care. Training for and filling health care jobs is not about filling bodies, but about considering the core competencies and skills needed, and having a workforce plan. And educators and health care leaders must intentionally train in teamwork and collaboration, have a growth mindset, and create environments of psychological safety on purpose rather than by chance.
From the NEJM Catalyst event The Health Care Workforce Crisis, sponsored by Optum, December 8, 2022.
From their perspectives as medical educators, Michaela Kerrissey, PhD, MS, Assistant Professor at Harvard T.H. Chan School of Public Health, and Catherine R. Lucey, MD, MACP, Executive Vice Dean and Vice Dean for Education at the UCSF School of Medicine, discuss moving from a mindset of recuperation during the health care workforce crisis to one of regeneration.
They begin by putting the current workforce crisis into historical context. “The [Covid-19] pandemic was in many ways just a very concentrated period of disruption,” says Lucey. “What is going to make it a different catalyst for change and transformation for our workforce is the fact that it required us to break the mold of everything we thought we needed to do in medical education, from how we interview to how we educate to when we graduate people.” Reforms that were discussed over the past couple of decades were considered desirable and feasible almost overnight. “It’s showed us that we should not be afraid to make medical education much more dynamic and adaptable to the circumstances we find ourselves in,” she says.
“I love this idea of having the crisis free organizations up and medical education up to break the mold,” adds Kerrissey. “And to think differently about what it is that is done and how it’s done.” In her work, Kerrissey collects qualitative and quantitative data directly from health care organizations, from the front line through to the C-suite, asking how they are working or doing things differently, what are the pain points, and what enables them to change and deliver high-quality care. She sees hospitals turning to break the mold as well.
It’s not just about the individual, but how the entire workforce is shaped, to meet the needs of every community.
Kerrissey asks Lucey what she sees happening when medical students get their first jobs, transitioning into residencies during this challenging time when the workforce is tight, and how she’s thinking differently about medical education and setting students up for success.
“An important thing for us to remember as medical educators and people who work in teaching medical students and residents — and all health professionals — is that our job is not just to escort talented people into the workforce. It’s actually to create a workforce,” Lucey says. Not failing to replenish the health care workforce has been a guiding principle during the Covid-19 pandemic, and graduating a talented class of well-trained individuals is the educator’s responsibility. “It’s not just about the individual, but how the entire workforce is shaped, to meet the needs of every community across the country.”
Medical education has a lot of appreciation for legacy, but it must become more dynamic. “It’s got to adapt to the circumstances we find ourselves in,” Lucey says. What are the new skills needed in this era? Educators must prepare graduates to solve the unsolved problems in the current workforce environment.
To envision 10 years down the road, educators need to know what health systems are thinking today. Lucey asks Kerrissey what health systems are grappling with and what competencies will be needed. “From the conversations I’ve been having at the top level in the last few months, they have never been more focused and more ready and eager to receive that class of graduates as they are right now, because the shortages are so massive,” Kerrissey says. At a hospital she visited recently, out of 7,000 employees, 3,500 were hired within the past 2 years, and the hospital still struggled to fill many vacancies. While an extreme example, all health care organizations are experiencing shortages. One executive, for example, looked at Kerrissey “completely flabbergasted” and said, “I don’t understand it. I can’t reconcile it. Where have all the people gone? Where have they gone? We have so many vacancies, we can’t fill them.”
Educators must prepare graduates to solve the unsolved problems in the current workforce environment.
First and foremost, attention and focus is needed on making sure the workforce pipeline is robust and thriving, even when it’s a difficult job to enter, says Kerrissey. Hospitals are very focused on the question of competencies. “It’s not just about filling bodies and cogs and machines,” Kerrissey says. “It’s about this very important topic that you bring up about what are the competencies and skills.” In the hospital with half their workforce as new employees, in describing how difficult their turnover problem was to Kerrissey, they told her they used to manage culture and teamwork in the hospital by chance, but now they have to be much more intentional about training people quickly in the culture of teamwork, collaboration, and the hospital’s expectations.
“That is a different way of thinking about who they’re looking for. It’s much more problem solvers, collaborators, people who can get out and solve the problems that are really big and really hard right now,” explains Kerrissey. This different set of skills involves more flexible opportunities for cross-training and working differently. “Not just filling the role, but helping to craft and create what that role should be when work like looks like it does today.”
This resonates with Lucey on the medical education side. Most of the medical problems treated today are things like chronic diseases, mental health, and so on, the “noncontagious epidemics” that are incredibly complex in origin and require solutions that are incredibly complex. It’s not enough to rely on biomedical instruction, though physicians must always be well-versed in it. “We need to understand the roles of society, the environmental crisis, sociological phenomena, things like structural racism,” she says. “All of those things have to be part of the knowledge base of the current physician because they all contribute to changes in the way people experience health and illness.” In response to this, UCSF has greatly expanded what they consider the foundational medical sciences and incorporated core concepts in a large number of scientific and scholarly realms.
Teaming and teamwork are crucial in care delivery and in continuous improvement within the health care system, adds Lucey, working with all areas such as pharmacology and social work. “[Teamwork] doesn’t just happen by throwing people together. You have to be educated to view the team as the source of power, the source of energy, not just one person.” Old models may persist, but this disruption to a team mindset, catalyzed by the disaster of the Covid-19 pandemic, has happened, as has thinking about what skills are needed to solve problems like health care disparities.
It’s not just about filling bodies and cogs and machines. It’s about what are the competencies and skills.
Kerrissey believes teaming is also a strategy for mitigating burnout. Tracking burnout and the factors that predict burnout, she says, “It has been striking in the data just how strongly people’s experiences of their team predicts reduced levels of burnout, reduced job stress, and increased intent to stay in their positions.” This makes sense intuitively, as most people’s daily work experience is with their teams. Many studies of burnout importantly focus on structures and access to supplies, but teaming also matters. The old adage that “people don’t quit companies, they quit managers,” is true. “People don’t show up for their managers, they show up for their teams,” Kerrissey says. “That’s a huge resource. It’s a resource for regeneration and it’s a resource for change. It’s a resource for people to keep showing up.” There are hard questions about how do you sustain that over time and make it work, but it’s fundamental to consider teaming when looking into burnout.
Lucey points to how powerfully and successfully health care employees have worked during the Covid-19 pandemic, giving it their all and more, with extraordinary commitment to professionalism. But where health systems fell apart [in the United States] was in not having a national workforce plan for health care professionals. We rely on the job market and the goodwill of medical school deans and residency program directors to staff health care organizations, but to solve the big problems in medicine, including maldistribution access issues and lack of understanding how diverse communities work, we need to think more strategically at the national or at least state level to ensure we are producing the right workforce, so that every health care facility is adequately staffed with everyone they need.
Broader responsibility for local communities and states is an important driver for workforce planning, from both a wider policy view and in individual environments experiencing difficult constraints, adds Kerrissey. During the pandemic, systems improved at collaborating with their peer organizations within their local geographies to start to address policy issues, and for large systemic issues to figure out not only filling in vacancies in numbers, but in putting a concerted effort behind the planning.
People come in with pretty good psychological safety on day one in health care organizations. Then it totally nosedives off a cliff.
This issue is multipronged, in terms of policy changes and organizations thinking about how they can get employees more quickly up to speed — we can’t wait a couple of years for someone to operate at their full level of practice. Psychological safety is important, as is establishing that safety quickly. “People come in with pretty good psychological safety on day one in health care organizations. Then it totally nosedives off a cliff,” Kerrissey says. “They then spend years trying to dig themselves out of the trough that they fell into, to get back to the level of psychological safety that they had on day one.”
Now, more than ever, employees need to feel psychologically safe to ask questions, make mistakes, and ask for help on day one, not years later. Health care organizations are starting to realize this and innovate, thinking more intentionally about “how do we make this not happen by chance, but be deliberate so that when we take somebody in new, we’re being smart about putting them in a team where we’re paying attention to psychological safety and people’s ability to team up so that that person’s landing in a good spot and then can learn and get up that curve a lot faster than they might otherwise,” she says.
A growth mentality in medical education and health professions education is all about the psychological safety to experiment intellectually with your teachers and partners. To be able to make a mistake and have the support to recover from that mistake is where growth occurs and learning happens, Lucey says. “Designing health professions, education systems as growth oriented rather than performance oriented — like ‘make sure you do well on this test or you can never be an orthopedic surgeon’ —is a critical element that we need to move forward with.”
We should also teach what it means to create psychological safety, Lucey adds. “Not just what it means to have a growth mentality yourself, but how do you actually structure your work environment? How do you build your team? How do you model vulnerability, uncertainty, ambiguity?” Adding psychological safety creation as a core competency of a health professional also requires self-compassion with one’s one mistakes, and it illustrates the need for creating safety for a diverse workforce, particularly in environments where groups have been historically white and male.
[Teamwork] doesn’t just happen by throwing people together. You have to be educated to view the team as the source of power, the source of energy.
“Making [psychological safety] part of the core competencies both in the training in school and then throughout the lifespan matters even more as time goes on for people, and it’s easy to forget,” says Kerrissey. Often, people are not promoted based on these competencies, but rather on being a technical star in whatever their specialty, and they are suddenly in a leadership position with everyone watching the behaviors they model and the culture they set. Rounding at hospitals, one of the most powerful things Kerrissey has seen on the topic of psychological safety is the creation of a common language for everybody to freely talk about their experiences. We often don’t have that language, which makes it difficult for psychological safety to exist. Health systems that do well in psychological safety are much more intentional with their processes around it, some even measuring it and collecting qualitative feedback, which displays intentional culture setting and enabling of teamwork.
At UCSF during the pandemic, Lucey says that leaders deliberately asked their employees what they could do to keep them working there, paying attention to people’s humanity and responding with chaplains, food, care for employees’ families, and so on. In times of high turnover, and at any other time, Lucey says that health care leaders must think about “what can we do on a daily basis to make it clear that we value the person you are, and we want to make sure we have removed unnecessary barriers and unnecessary stresses to you from your work, so that you can be the person that your patients need, you can be the person that your teammates need?” Part of educators’ work in designing a workforce is not only to create frontline care providers, but to create future leaders.
Catherine Lucey and Michaela Kerrissey have nothing to disclose.
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