National Plan for Health Workforce Well-Being (2022)

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7 Priority Area: Recruit and Retain a Diverse and Inclusive Health Workforce Promote careers in the health professions and increase pathways and systems for a diverse, inclusive, and thriving workforce. “The energy of caring for the sickest of the sick and the collaboration between all physicians and nurses/staff was uplifting and life affirming in the darkest of times.” - Frontline Health Worker1 Health care and public health workers were lauded as heroes ear- ly in the COVID-19 pandemic, as they operated under high-pres- sure circumstances and navigated disease uncertainties. Howev- er, stress, burnout, and mental health challenges experienced by frontline workers have accelerated departures from direct patient care and disease prevention and monitoring across the country. As mentioned earlier, the emotional well-being of clinicians of color was also disproportionately impacted during COVID-19, as they experienced heightened discrimination and harassment. Nation- al media highlighted unacceptable working conditions for health workers; concerns for the safety of the patients in their care due to persistent staffing shortages; and in many cases, the inability to work and advise at the top of their training and education as health care and public health specialists (Yong, 2021, 2020). Cultivating multidisciplinary team-based care is important not only to effi- 1 For background on this quote and those in other chapters, visit the NAM’s Clinician Burnout Crisis in the Era of COVID-19: Insights from the Frontlines of Care webpage at: https://nam.edu/initiatives/ clinician-resilience-and-well-being/clinician-burnout-crisis-in-the-era-of-covid-19/. 59 

60 | National Plan for Health Workforce Well-Being ciently and effectively navigate the complexities of the U.S. health care delivery system, but also to support health workers in provid- ing safe patient care and increasing their overall well-being (Sin- sky et al., 2020b; Smith et al., 2018). Health systems should fully leverage the education, certifications, and experiences of all care team members, fostering a clinical care environment of mutual professional respect (Smith et al., 2018). The nation must acknowledge that a functioning U.S. health sys- tem requires ongoing care for and investment in health workers. Demonstrating the importance of the health workforce includes prioritizing retention of the existing skilled workforce, investing in continuing education, and restoring a sense of inclusion and meaning in health care and public health education and training. If the goals described in earlier chapters are not achieved, posi- tive work and learning environments are not cultivated, barriers to daily work are not removed, and well-being is not institutionalized as a long-term value, many applicants and potential future health professionals may be discouraged from pursuing or maintaining these careers–to the detriment of the nation’s health. Furthermore, it is paramount to promote careers in the health professions to build a strong health workforce that reflects a grow- ing, aging, and more racially and ethnically diverse U.S. popula- tion, while also actively advancing health equity. The historical and continued lack of diversity and inclusion in the health workforce, which overtly and covertly reinforces exclusion of people of color, people who are LGBTQIA+ (lesbian, gay, bisexual, transgender, queer/questioning, intersex, and ally/asexual), people with dis- abilities, and other underrepresented groups in the health pro- fessions, is another structural barrier to recruiting and retaining a diverse and inclusive workforce. Although unprecedented surges in medical and public health school applications were reported in 2021, it is unclear how they have affected enrollment in training programs, and workforce shortages remain. The shortages are especially acute among professions such as aides, assistants, and nurses (e.g., a shortage of more than 1 million nurses is expected). In regions where shortages are chronic, such as rural areas where access to health care is limited, the recruitment of health workers is uniquely challenging (Bhatnagar et al., 2022; Pollack, 2022). Ad- PREPUBLICATION COPY - Uncorrected Proofs 

Recruit and Retain a Diverse and Inclusive Health Workforce | 61 missions offices speculate this application surge is partly because COVID-19 accelerated people’s motivations to join the pandemic response and help alleviate social injustices (Boyle, 2021; Warnick, 2021). In response, educational systems must adequately scale to meet the demands of incoming students and ensure there are enough placements, embracing cohorts that are more diverse than any before 2021 through equitable and holistic admissions processes and cultural humility practices (Boyle, 2021). Insufficient num- bers of nurse faculty and clinical placements continue to severely limit the capacities of nursing schools to accept all qualified ap- plicants and train future practitioners (NASEM, 2021). While train- ing new health professionals takes time, efforts to advance team- based care can help address workforce shortages in the near-term through the benefits of well-being for high-functioning teams and improved patient care (Smith et al., 2018). Caring for others is a noble calling, and health care and public health roles offer numerous opportunities for intellectual grati- fication and interactions with people from all facets of life. Soci- ety needs to address the challenges and leverage lessons learned during the pandemic to commit to improving the health system, so health workers and patients flourish. It does not matter if resil- ience is instilled in individual future health workers if they enter systems that diminish their abilities to thrive (NAM, 2022). PREPUBLICATION COPY - Uncorrected Proofs 

62 | National Plan for Health Workforce Well-Being Priority Area: Recruit and retain a diverse and inclusive health workforce. The size and composition of the health workforce Goal 1 reflects the demand and diversity of the U.S. population. Academic Institutions, Clinical Training Programs, and Accreditation Bodies Actors Federal, State, and Local Governments Health Systems 1A. Train, hire, and retain people from underrepresented and marginalized communities in health care and public health (see actions to support diverse, equitable, accessible, and in- clusive settings in Chapter 1). 1B. Provide debt relief opportunities for students and workers through employer programs and expanded eligibility for loan forgiveness. 1C. Invest in educational pathways and programs such as: • pipeline programs and partnerships among high schools, technical schools, and universities to allow emergency medical technicians, certified nursing assistants, and armed forces medics to apply work hours toward clinical professions; • targeted scholarships or tuition support for nursing students or nursing educators to increase workforce Actions numbers; and • onsite graduate school and professional development programs to retain experienced nurses. 1D. Allow extensions to residency cap-building periods for new graduate medical education programs to address recruitment, resource availability, and program operations. 1E. Fund graduate nurse education programs to address significant worker shortages across the health system. 1F. Expand and scale support for a national Reserve Nurse Training Corps using the military’s Reserve Officers’ Training Corps as a model, including undergraduate tuition payment and service commitment. 1G. Leverage the role of the U.S. Surgeon General to prioritize and communicate the significance of addressing health workforce well-being. PREPUBLICATION COPY - Uncorrected Proofs 

Recruit and Retain a Diverse and Inclusive Health Workforce | 63 The health system retains health workers who have Goal 2 personal caregiving responsibilities. Academic Institutions, Clinical Training Programs, and Accreditation Bodies Federal, State, and Local Governments Actors Health Systems Private and Non-Profit Organizations 2A. Revise policies to offer flexibility for clinical schedules, job-sharing, remote work, and opportunities to re-enter the workforce. 2B. Increase the duration of and pay for parental leave. Actions 2C. Invest in and improve childcare opportunities. 2D. Increase diversity in leadership, management, and health care teams. 2E. Review compensation to ensure equitable practices across the organization. PREPUBLICATION COPY - Uncorrected Proofs 

64 | National Plan for Health Workforce Well-Being Health care environments are person-centered and Goal 3 safe for health workers. Academic Institutions, Clinical Training Programs, and Accreditation Bodies Federal, State, and Local Governments Actors Health Systems Health Workers Private and Non-Profit Organizations 3A. Establish and follow staffing plans that reflect effective team composition and balanced workloads to provide safe patient care. 3B. Create clear criteria for the appropriate use of mandatory Actions overtime to ensure it is applied only in emergency circum- stances. 3C. Fund testing and implementation of interventions that improve occupational safety for health workers. PREPUBLICATION COPY - Uncorrected Proofs 

Recruit and Retain a Diverse and Inclusive Health Workforce | 65 Health workers have the infrastructure to support their Goal 4 work to improve population health. Federal, State, and Local Governments Health Systems Actors Health Workers Insurers and Payers Patients 4A. Incentivize payers to invest in providing quality com- munity resources to address barriers that patients face in obtaining care and attaining their full health potential (the social determinants of health [SDOH]). 4B. Provide greater flexibility for Medicare Advantage to reimburse health workers for addressing SDOH. 4C. Explore the integration of SDOH as a factor in payment Actions policy and the infrastructure needed to support connections to social services. Elements include: • incorporating standardized SDOH billing codes into health worker IT systems, such as electronic health records (EHRs) and care management platforms; • aligning incentives for senior and frontline leaders to address SDOH for patients and populations; and • recognizing and rewarding health workers for ad- dressing SDOH. PREPUBLICATION COPY - Uncorrected Proofs 

66 | National Plan for Health Workforce Well-Being Health workers and learners are inspired and equipped Goal 5 to meet the challenges of caring for the nation. Academic Institutions, Clinical Training Programs, and Accreditation Bodies Federal, State, and Local Governments Health Systems Actors Health Workers Media and Communications Professional and Specialty Societies 5A. Each profession creates a future vision of what it means to fulfill their duties. 5B. Create incentives to facilitate team-based care. 5C. Administer surveys to students pre-matriculation through graduation to assess and respond in a timely man- ner to personal and professional experiences along the edu- cational pathway. 5D. Invest in continuing education. Actions 5E. Develop health worker reserves to address emergent needs and large-scale disasters. 5F. Conduct message testing and communications research to develop media campaigns that highlight the joy and ful- fillment of the health professions, as well as health worker contributions during the COVID-19 pandemic. 5G. Launch a campaign with influential voices in health that targets multiple sectors of society. NOTE: The list of actors in this table is not exhaustive. Many of the actors named in this table will need to plan and coordinate their actions with each other as part of a systems approach to health workforce well-being. PREPUBLICATION COPY - Uncorrected Proofs 

Recruit and Retain a Diverse and Inclusive Health Workforce | 67 RELATED RESOURCES2 1 Examine Policies and Practices • Strategies: Policy Strategies for Addressing Current Threats to the U.S. Nursing Workforce (Costa and Friese, 2022) • Survey: Matriculating Student Questionnaire (Association of American Medical Colleges) Strengthen Leadership Behaviors • Discussion Paper/Action Items: Physician Well-Being 2.0: Where We Are and Where We Are Going (Shanafelt, 2021) • Discussion Paper/Action Items: Getting Through COVID-19: Keeping Clinicians in the Workforce (Barrett et al., 2021) • Discussion Paper: A Call to Action: Align Well-Being and An- tiracism Strategies (Barrett et al., 2021) 2 For additional resources, visit the NAM’s Resource Compendium for Health Care Worker Well-Being webpage at: https://nam.edu/compendium-of-key-resources-for-improving-clinician-well-being/. PREPUBLICATION COPY - Uncorrected Proofs