Constant Staff Shortages Are A Growing Factor In U.S. Hospital Development

Despite the broader societal and economic push to move past the effects of the pandemic, the brutal toll it continues to extract from the healthcare sector has seemingly become endemic to the industry.

Staff shortages have proved to be such an intractable problem for hospital systems that they have begun to affect design and planning decisions for new developments and renovations, panelists said Tuesday at Bisnow’s State of Philadelphia Healthcare Summit at the W Philadelphia.

“We have a client who recently came to us and said, ‘We really need to do more with less,’” Schneider Electric Healthcare Strategic Account Executive Braheem Santos said at the event. “‘With our nursing staff specifically, you know, the numbers just aren't there. So are there things that we can do from a technological standpoint to help us [adapt to] that reduction of our full-time employees and staff?’”

The ability of a system to hire and retain healthcare providers, especially nurses, has a direct impact on the patient experience, from health outcomes to customer satisfaction, panelists said. Despite such paramount importance, the provider experience often winds up on the cutting room floor when project costs rise beyond a project’s budget, EwingCole principal Saul Jabbawy said.

“Now, everybody wants to do the right thing,” Jabbawy said. “But given the parallel structure of costs, when you find out that a project that was on budget two months ago is 30% over budget now, when you didn't even change anything, there is more pressure on square footage.”

The experience of healthcare systems backtracking on employee-centered spaces during a project’s planning process in favor of treating more patients long predates the pandemic. But with costs of every kind rising rapidly over the past couple of years, Thomas Jefferson University Hospitals Senior Vice President of Real Estate and Facilities Clayton Mitchell had to draw a line in the sand, he said.

“I don't even like to talk about projects being too expensive anymore,” he said. “The real question is, do we meet our business case? Because the market’s always going to be fluctuating.”

To try to stay within budget in such an environment directly threatens the chances that a development will actually meet a system’s needs over the long term, Mitchell said.

“When the project is underway, my job is to help the architects and the general contractors and all the consultants execute their original work plan to the extent it’s possible,” he said. “I don't want to cut scope. I don't want to do a whole bunch of funky deals. I want that person, that entity to execute as close to their original work plan as possible.”

Across all three panels, speakers from all over the spectrum of healthcare real estate professions stressed the importance of getting a project’s plan right the first time, with all possible stakeholders getting a chance to weigh in and point out others’ potential blind spots. Ultimately, the final execution of a hospital, outpatient care facility or medical office building is a reflection of priorities from a system’s leadership, said Allison Wilson-Maher, University of Pennsylvania Health System vice president of real estate, design and construction.

“We recently converted a staff break room to a new chair[person’s] office, and that sends a message to people,” Wilson-Maher said.

It has never been harder to keep a hospital appropriately staffed, but the problem looks to worsen in the years to come. In addition to an elevated mortality rate compared to the broader population, the nursing profession has suffered attrition from health issues and worker burnout over the past three pandemic-affected years.

There are more job openings for registered nurses than for any other position in the U.S. workforce, according to American Nurses Association research. The number of job openings for nurses was expected to rise by 9% from 2016 to 2026, the fastest of any profession, according to Bureau of Labor Statistics data reported in a National Institutes of Health research paper this year.

“It's non-revenue-generating, but what's the cost of trying to recruit and retain your staff?” HDR interior design principal Sara Gally said. “There's still a financial implication there.”

Given the context, hospital systems have begun testing methods for supplementing workforce retention and recruitment efforts with plans for adapting to higher patient-to-nurse ratios, Jabbawy and Santos said. Artificial intelligence, already widely used to automate the patient intake process, can be used in ways decidedly unlike ChatGPT and its ilk. 

One NIH study of AI-based monitoring systems for fall risk among patients found the monitoring reduced such risk by 35%, Jabbaway said. Such a system uses vital signs like hydration and heart rate in addition to location tracking to require fewer visits from nurses.

As much as it may help, AI can never replicate what actual nurses and doctors provide, panelists said. Beyond machine learning’s technological limitations, human elements such as empathy and intuition are central to patient care, including considerations in hospital design.

“One of the things that we talk about a lot is the placement of the toilets,” Wilson-Maher said. “I know that is very unsexy. But it's really important. And sometimes those toilets are not just used for bodily functions; sometimes our providers go in there and cry because they don't have respite areas that are close. It's the only place they can go that's private.” 

Ultimately, a system’s real estate head can do very little to change the trajectory of the labor crisis in the healthcare industry. Unadjusted median wage growth was 9.92% for nurses and 37.6% for physicians between 2001 and 2017, according to a 2021 research paper published in Human Resources for Health.

From the start of the pandemic through late 2021, median healthcare pay rose at a pace slower than the overall labor market, according to BLS data reported by Fierce Healthcare. Crucial gains have been made in some hospital systems since then, often driven by protests and organization efforts by the nurses themselves.

But higher pay isn’t enough by itself to prevent burnout, panelists said, and until the demands placed on providers can be lightened, those responsible for the buildings themselves are more aware than ever of the importance of workers’ plight. 

“In the acute care environment, when people are working 12-, 14-, 18- and 24-hour shifts, it becomes increasingly important that we take care of our providers in many different ways,” Wilson-Maher said. “And the way that we do that is through our environment.”

CORRECTION, APRIL 10, 10:05 A.M. ET: A previous version of this article misstated the company name of EwingCole. This article has been updated.