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In Depth: The Nurse Staffing Crisis

My approach to this admittedly complex subject will be to address the challenge in two segments, The Effect of COVID Care and The Effect of Vaccine Mandates.
The Effect of COVID Care
The cumulative stress of caring for patients during the pandemic, initially associated with concerns regarding access to proper Personal Protective Equipment and the wait for a vaccine, and now changing to frustration with additional waves of patients, vaccine resistance, and – remarkably – a change from nurses as heroes to nurses as agents of oppression, has caused many to evaluate their options outside of bedside care.

Healthcare workers have been pushed to their limits during the COVID-19 crisis, and some are considering a change in profession or setting as the country marks one year into the pandemic.

“Our workforce is tired, people are leaving nursing,” Tucson Medical Center CEO Judy Rich said.

The pandemic has caused massive short-term disruptions to the U.S. economy and labor market, with 14.7 million jobs overall shed between February and June of last year, according to the Bureau of Labor Statistics. The healthcare industry was no exception, and still has about 500,000 jobs to recoup to get back to pre-pandemic levels.

The external environment, which includes both challenges – homeschooling, lockdowns – and opportunities – telehealth and non-clinical care, influences nurses’ options and decisions.
Healthcare Dive reports:

That’s in part due to nurses accelerating their retirement plans, or simply looking for other work outside of clinical care. Scheduling conflicts are another challenge drawing nurses with families to other jobs.

“Some have had to cut back so that they can home school, some have had to make changes, maybe into a different type of schedule where previously they could work a night shift at the hospital and maybe now they need to work remotely for an insurance company,” Hansen said.

The problem is widespread and pervasive.
McKinsey reports:

Twenty-two percent: That’s how many nurses indicated in a recent McKinsey survey that they may leave their current position providing direct patient care within the next year. At a time when nurses are most needed, a significant strain in the workforce exists due to the COVID-19 pandemic. Health systems and other employers of nurses recognize this challenge and are actively designing and deploying new strategies.

Of the 22 percent of nurses who indicated they may leave their current positions, 60 percent said they were more likely to leave since the pandemic began, driven by a variety of factors, with insufficient staffing, workload, and emotional toll topping the list. This level of turnover is costly and disruptive for healthcare systems, and can impact morale, disrupt the nurse and patient experience, and exacerbate an already pressing shortage of qualified talent in key geographies and specialties.

With nurses leaving, temporary staffing agencies have rushed to fill the void, but are doing so at substantial additional costs to their health facility partners.
CIDAP reports:

Staffing agencies have been thriving after the first-wave furloughs gave way to a mix of COVID needs and backlogged procedures. To help, regulations have become more flexible during the pandemic to allow nurses to move from state to state more easily, says John Maaske, the CEO of Triage Staffing, based in Omaha, Nebraska.

By Maaske’s estimates, about 15% of positions Triage has right now are COVID crisis jobs, although many of the “normal” jobs have crisis rates tied to them. While the average wait time between a job posting and fulfillment is 2 to 3 weeks, Triage has continued to improve operational efficiency and has plans to roll out technology that automatically connects a qualified candidate with an opening by the end of March 2021.

Deployment records may be rising, but every new travel nurse could mean one fewer in-house nurse in the grand scheme of things. “It’s a ‘rob Peter to pay Paul’ situation,” says Katie Boston-Leary, PhD, RN, MBA, MHA, director of nursing programs and co-lead for Project Firstline, a partnership between the American Nurses Association and the Centers for Disease Control and Prevention. “They’re not hiring people out of school. They’re hiring nurses who are in practice.”

The nurse staffing shortage has significant implications for clinical care and patient outcomes.

Forbes reports: 

The nurse shortage negatively affects healthcare facilities across the United States by not allowing these facilities to meet their patients’ needs while creating nurse burnout and high turnover rates. The global pandemic has made things worse for these nurses, patients and the general industry by adding stress to these individuals. The mass influx of patients has increased patient ratios that adversely affect patient care.

… and caregivers working through the pandemic will carry with them long-lasting physical and mental effects: 

The Atlantic reports:

No one has endured the past year unscathed, but America’s health-care workers have witnessed the worst of it while trying to keep the rest of us healthy and safe. They’ve fought for PPE, and with patients and visitors who refuse to wear masks. They’ve watched their patients give birth alone, suffer alone, die alone. Hundreds of thousands got sick themselves, and many more lived with the daily worry of bringing the virus home to their loved ones. Many began to wonder if it’s worth it.

… and there’s the “skills gap”.
MedPage Today reports:

During the fourth wave of the COVID-19 pandemic, hospitals have closed beds, shut down elective surgeries, and called in federal assistance due to a shortage of a critical healthcare resource — nurses.

But the current nursing shortage isn’t just in the numbers. The exodus of experienced nurses leaving the front lines, as well as turnover among early-career nurses, have led to a widening skills gap, creating major implications for a healthcare system in need.

The New York Times reports:

There were more than three million nurses in the United States in 2019, according to the Bureau of Labor Statistics, which estimates 176,000 annual openings for registered nurses across the country in the next few years. But those projections were issued before the pandemic.

Peter Buerhaus, an expert on the economics of the nursing work force at Montana State University, is especially rattled by two data points: A third of the nation’s nurses were born during the baby boom years, with 640,000 nearing retirement; and the demographic bulge of aging boomers needing intensive medical care will only increase the demand for hospital nurses. “I’m raising the yellow flag because a sudden withdrawal of so many experienced nurses would be disastrous for hospitals,” he said.

..and if that wasn’t bad enough…
The Effect of Vaccine Mandates
With the Pfizer vaccine transitioning from Emergency Use Authorization to FDA-approved, and the Biden administration tying Medicare reimbursement to vaccinated staff, vaccine hesitancy – refusal – among nurses is adding to the crisis, as these professionals quit or are fired by their employers.
With the percentage – the sheer number of nurses with strongly held anti-vaccination beliefs, those employers are caught between a rock and a hard place.
STAT reports:

It’s hard to predict how many people will actually quit their jobs over the vaccine mandate. In June, after a federal judge dismissed a lawsuit brought by health care workers at Houston Methodist Hospital over its vaccine mandate, more than 150 workers quit or were fired.

The Federal Government’s mandate has the potential to accelerate the trend.

STAT reports:

Health care workers had priority access to the COVID-19 vaccine back in December 2020, but nine months later, many are still reluctant to get the shots. Vaccination rates remain low in some states and among some subgroups of health care workers such as nursing assistants. As part of his push to get more Americans vaccinated, Biden has essentially told 17 million health care workers: Get vaccinated or get out. He has not offered them the testing option he’s given workers in most other industries.

Bloomberg explains the conundrum succinctly

Mandate the vaccine, and some of your nurses will quit. Don’t mandate the vaccine, and some of your nurses will get Covid—rendering them unable to work, or even landing them in the very intensive care unit where they normally work. For a hospital administrator who’s been dealing with nursing shortages escalating throughout the pandemic, this is the dilemma.

“It’s a cynical question, but what gets us to losing the higher amount of staff?” says Alan Levine, chief executive officer of Ballad Health, which has 21 hospitals and other centers serving patients in Kentucky, North Carolina, Tennessee, and Virginia. He decided not to require vaccinations for his healthcare workers after modeling suggested he could see 15% of nurses, or as many as 900, leave if he did. That’s more than he anticipates losing to Covid-19 quarantines and illness, even with the most recent surge filling up the network’s ICUs and 130 staffers quarantining on a single mid-August day. At Ballad, 97% of doctors are vaccinated. Among front-line nurses, he estimates vaccination rates hover around 50%.

Sadly, none of the solutions for the challenge are simple or easy to implement. Retention is a consistent theme, however.
Elsevier posted

These nurses have seen it all and want to feel like they work for a hospital that hears their voices and shares their commitment to providing excellent care and high-quality patient experiences.

In their day-to-day work, experienced nurses know they need standardized, evidence-based tools to make an impact. And they need to be supported by an engaging, continuing education system. If they’re struggling with siloed tools and a one-size-fits-all learning program, they may opt out for more fulfilling jobs in another field.

To combat burnout and keep them engaged, hospitals need to foster practice improvement and professional growth with integrated, evidence-based education tools and personalized learning paths.

Empowering nurses with confidence and competence are critical to combatting today’s nursing shortage.

Gallup posted

For the 18th year in a row, Americans rate the honesty and ethics of nurses highest among a list of professions that Gallup asks U.S. adults to assess annually. Currently, 85% of Americans say nurses’ honesty and ethical standards are “very high” or “high,” essentially unchanged from the 84% who said the same in 2018.

With the profession under siege, and the effect of the shortage weighing heavily on the healthcare system, we will need to support and encourage our nurse colleagues in a manner that preserves their essential contribution to that system.
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Paul Hudson, FACHE
Chief Operating Officer