Defining the Problem
The COVID-19 pandemic was undoubtedly an accelerator for departures in healthcare. Recruitment and retention have posed challenges in the field for years, but since the pandemic, strategies pertaining to these metrics have become increasingly important to the survival of the healthcare workforce. In a plenary session at the NCCN 2023 Annual Conference, a panel of experts working in an array of leadership positions discussed the scope of the problem and offered their own unique solutions to increasing recruitment and retention at their respective institutions.
“Pre-pandemic, we saw too few nurses and doctors coming out of school, particularly in oncology,” said Rebecca L. Caires, MBA, Vice President of Operations, Robert H. Lurie Comprehensive Cancer Center of Northwestern University. “So, we knew there were going to be problems, and the pandemic exacerbated those.”
The pandemic led to an increase in early retirements and healthcare workers leaving the industry, with many moving out of state. “The exodus was expedited, even though we knew there were too few people coming out of schools to backfill those positions,” she added.
In the past year or two, she added, efforts at Northwestern Medicine have focused on increasing retention across the network as a key initiative, with a goal of reducing first-year turnover and vacancy rates by at least 5%. “Everybody in the organization—from leadership to the local managers to the employees themselves—are really in this together,” Ms. Caires said.
This initiative uses a 5-armed approach: working within communities and schools to recruit candidates into the pipeline, reconsidering total compensation based on employee feedback regarding desirable packages (including competitive salary, benefits, and tuition reimbursement), reevaluating work–life balance, looking at innovative ideas around modeling care, and adding services that allow advance practice providers (APPs), nurses, and physicians to operate at the top of their license.
Anne H. Gross, PhD, RN, FAAN, Senior Vice President for Patient Care Services and Chief Nursing Officer, Dana-Farber Cancer Institute, and NCCN Best Practices Committee member, added that the baby boomer generation is retiring and becoming bigger consumers of healthcare resources. Unsurprisingly, the COVID-19 pandemic also accelerated this process and added to the workforce shortage.
Todd A. Pickard, MMSc, PA-C, Executive Director of Advanced Practice, The University of Texas MD Anderson Cancer Center, argued that retention was an issue long before COVID-19 (although it was certainly made worse by the pandemic). “In my 25 years as an APP, I’ve found that people in the advanced practice world tend to get a mid-career ‘itch,’ where they start asking themselves what’s next and how they might be able to contribute more,” he said. “Systems really need to be aware of that.”
According to Mr. Pickard, this “itch” tends to happen at about the 5- to 7-year mark for APPs. Efforts at MD Anderson are focused on recognizing that desire to be challenged as well as encouraging and supporting their staff to grow within the system.
Kristi Stiffler, MPH, Vice President of Clinical Research, Fred Hutchinson Cancer Center, added that attrition in central clinical trials offices has been particularly high since COVID-19. “Our experience came to a head when one of our largest research groups lost more than 80% of their staff over about 3 months,” she said. “So, we had to suspend all enrollments in a very large research group. I think that got the attention of everyone in the center and made us all come together to think about what our strategies were for not only recruiting, but retaining, staff and looking at the reasons people were leaving.”
The “itch” was one of the culprits at Ms. Stiffler’s institution as well (occurring at roughly the 1-year mark, compared with about 3 to 5 years before the COVID-19 pandemic), but high attrition also led to remaining staff feeling burned out and overwhelmed. “This led to what our medical director called the ‘death spiral’ within study teams,” she admitted.
They implemented initiatives to prevent this “spiral,” focusing on offering opportunities for advancement or exposure to other research teams/roles and providing centrally available resources to augment teams feeling stressed about their workload. She added that the healthcare shortage has led to a plethora of opportunities for people entering the workforce, so development opportunities should be offered early in careers; “really from the moment someone comes into the institution,” Ms. Stiffler admitted.
At Northwestern Medicine, Ms. Caires and her colleagues are focused heavily on recruitment and retention of employees in year 1, conducting regular surveys of new hires, providing leaders with a toolkit for working with new employees, and developing clinical ladders for APPs.
Dr. Gross noted that protected time in residency programs is important for newly licensed nurses, as this time is critical for learning and developing clinical decision-making skills. “Without mentoring and support, that first year coming into healthcare can be overwhelming,” Dr. Gross said. “And, as we’ve seen, people are leaving [in their first year].”
Once nurses are through that first year, she reiterated that people coming into the workforce now want a clear career path and flexibility in their work–life balance. “It’s different now; the COVID-19 pandemic has affected all of us in interesting ways,” Dr. Gross commented. “People have had a chance to evaluate their lives and their careers; they’re making changes and we need to respond to them.”
Arriving at Solutions
To address issues with retention while keeping an eye on flexible work–life balance, Ms. Stiffler and her colleagues at Fred Hutchinson have begun hiring in cohorts, so staff can train together in peer groups, with hands-on training augmented by existing senior staff. They work with new employees to clearly define expectations and career paths, so they know exactly what is required to advance in their field, and they provide professional skill training to create even more opportunities for advancement. They’ve also implemented various electronic systems and migrated documents to those systems to support teams working remotely. They make these support systems known to their employees, emphasizing the institution’s investment in their future.
“We’ve also started hiring before we have an immediate need to fill a specific role,” Ms. Stiffler explained. “We’ve hired people with the understanding that they’ll have opportunities to work across different disease groups, and even at different locations across our centers.”
According to Mr. Pickard, a crucial factor in retaining APPs is remembering their potential and leveraging everything they have to offer, rather than confining them to a box. “It’s critically important to remember that APPs are really stem cells, and they can morph and develop into whatever gaps need to be filled within a clinical practice,” he said. “By virtue of our profession and how we’re trained, we’re ready to move wherever the need is.”
His institution is amenable to flexible remote work, offering multiple opportunities for APPs, such as virtual care, “askMDAnderson,” and serving as a team’s at-home support system. He encourages APPs to discuss these options with a supervisor if they desire more flexibility in their role.
Ms. Caires stressed the importance of leaders maintaining visibility within their organizations. “From day one, managers should know the goals of every individual [under their management],” she said. “And it is individualized; it is no longer a one-size-fits-all approach in terms of the career paths, needs, and wants of our employees.”
Managers at Northwestern Medicine are given a specific toolkit detailing what to ask of their staff, when to ask it, and when and to what extent they need to be visible. “It’s about hard-wiring those face-to-face, individual conversations about people’s wants and needs,” Ms. Caires added (keeping in mind that those wants and needs may vary widely from person to person).
Dr. Gross admitted that, although leaders are highly visible in her organization, they have “not quite figured out” the move to more remote work. However, after the pandemic crisis began to ease, they implemented a program aimed at listening to clinicians and patient-facing staff (led by Dr. Gross, the Chief Medical Officer, and the Chief Operating Officer). They’ve now met with more than 500 individuals from all areas of the institute to hear feedback on the systems and processes most disrupted by the pandemic, and they are developing action plans to address them.
“Interestingly, across all disciplines, a lot of the same themes are emerging: connection, communication channels have broken down, and many people feel isolated,” Dr. Gross said. “We can’t fix everything, but we’re going to start with the biggest issues. I think people appreciate it, and it helps them to feel involved in creating the solutions.”
Although the panelists all hail from large academic centers, Mr. Pickard offered advice for smaller independent practices hoping to retain new APPs: tap into resources from ASCO and the Community Oncology Alliance (COA) on onboarding and mentoring APPs, let them know their new workplace is invested in their growth, connect them with the appropriate educational resources, and engage them in sharing their own ideas on what could make the practice better, he advised.
Ms. Caires added that leaders can help employees to identify and develop skill sets they may not have even known they had. “When you invest in that relationship, you not only help that person develop and retain them, you also build trust,” said Mr. Pickard. “They feel seen and valued, and they’re more likely to want to stay.”
Dr. Gross emphasized that traveling “temp” nurses and other temporary staff should be used only in an emergency, as their presence can be demoralizing to long-term staff making a fraction of the pay. “I used more temps during the pandemic, but we really need to get away from that if we want to retain employees and make them feel like we’re committed to them,” she said.
At the end of the day, people in all professions want to be engaged with, heard, and recognized. “The work is never enough by itself. If you don’t have meaning and purpose, and if you don’t feel respected and valued, you just feel frustrated,” said Mr. Pickard. “We now work very hard to make sure that doesn’t happen.”
