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Are your nurses heading for the door?

The great nursing exodus

November 2021

ASK Claire Zangerle, DNP, MSN, MBA, RN, the difference between the nursing shortage before the pandemic and now, and she has a ready answer.

“Before covid, our vacancy rate was 10% and our turnover rate was around 12% a year,” says Dr. Zangerle, chief nurse executive of Pittsburgh’s Allegheny Health Network, with 14 hospitals. “Now our vacancy rate is in the low 20s, and turnover is in the mid 20s. It’s not a pretty graph to see on paper.” As for whether that exodus has at least slowed down, Dr. Zangerle—speaking in the first week of October—says it has not. “I had four nurses leave yesterday.”

In part, the pre-pandemic nursing shortage was due to the fact that nurses now have an unprecedented array of career options, and they don’t need to be tied to a certain number of long hospital shifts. But that years-long shortage—which Dr. Zangerle says was “absolutely manageable”—has ballooned during covid outbreaks, with nurses burning out and taking early retirement, migrating to other jobs, or electing to stay with homebound children or grandchildren.

“Communities that aren’t as disrupted by covid likely aren’t seeing as much workforce disruption.”

Gregg Miller, MD Vituity

~ Gregg Miller,
MD Vituity

While that’s been true across all health care settings, nurses have really been exiting from hospitals, opting for easier hours in outpatient practices, for instance, or a job at home fielding calls for insurance companies. Or, if they do stick with inpatient care, many—particularly younger nurses—are being lured away by travel agencies that offer two or three (or many more) times the salary they earn as employees.

Dr. Zangerle estimates that out of the 2,800 inpatient nurses in her health system, she has lost 200 to such staffing agencies. The newest wrinkle, she reports: Agencies are picking off her nurses for her across-town competitors, paying them much more than she can while allowing them to continue to live at home.

“They can’t pass up the money,” she notes of the defecting nurses. “I try to get them to pick up a shift for us PRN.” She knows some travelers will eventually come back to once again be part of a more permanent organization. But for now, even if the pandemic and its attendant burnout subside, “we have to figure out how to make the bedside attractive again.”

Regional differences
While the current nursing shortage is country-wide, “when you look at different surveys, you get different answers as to where turnover is highest,” says Gregg Miller, MD, chief medical officer for Vituity, a multispecialty physician-led partnership with more than 500 hospitalists nationwide. “The difference is likely related to when the surveys were done and where those communities were at that point in the covid pandemic.”

“We’re working with the same nurses on the same floors across all three sites as we were during the first surge.”

Peter-Luyeho, MD

~ Peter Luyeho, MD
Henry Ford Health System

Probably, Dr. Miller adds, “turnover is greatest when there’s the most need. Not only are we losing nurses, we’re losing them in the time and places we need them the most. Communities that aren’t as disrupted by covid likely aren’t seeing as much workforce disruption.”

Detroit’s Henry Ford Health System is a case in point. While local coverage reports that the health system plans to hire several hundred nurses from overseas, Peter Luyeho, MD, interim division head for hospital medicine, says that he and his 55 hospitalist colleagues across three hospitals haven’t been affected by any nursing shortage.

“Our census has grown, but that’s because we’re growing our group and we’ve added more beds to cover,” says Dr. Luyeho. By any measure, he adds—getting patients out of the ED faster, doing more early discharges—the hospitalists aren’t running into problems due to too few nurses.

“We’re working with the same nurses on the same floors across all three sites as we were during the first surge,” says Dr. Luyeho. That first surge came in December 2020-January 2021, with another in April this year. As for the impact on his group of delta this summer, “I wouldn’t even call it a wave. Right now, we’re just living with covid.”

The impact of vaccine mandates
The same is true in Sacramento, Calif., where Brent Jackson, MD, MBA, is vice president/chief medical officer at Mercy General, part of Dignity Health. His hospital, which is staffed for around 200 beds, suffered a December-January covid surge and one this August.

“Both covid and staff shortages are affecting measures of hospital harm.”

Amit Vashist, MD, MBA

~ Amit Vashist, MD, MBA
Ballad Health

But both outbreaks, Dr. Jackson says, “were pretty easy for us to absorb, and we were able to relieve smaller sister facilities when they were overwhelmed.” It helped with delta this summer that “our hospital is within the zip code with the highest percentage of vaccinations in Sacramento County.”

As for nurses, “we had some covid attrition,” which at times meant that a break nurse had to pick up a roster of patients and couldn’t provide breaks for bedside nurses. And Dr. Jackson was worried when California’s state vaccination mandate for acute care workers (be vaccinated or be tested twice a week) took effect at the end of September.

But “out of an employee pool of around 2,000 nurses, perhaps 20 may end up resigning,” he points out. That’s had some scattered effects—only two of the hospital’s four cardiac operating rooms could be staffed some days in early October, for instance—”but overall, it’s been minor. We’ve been generally able to get other nurses to pull extra shifts to cover, and we pay them an extra-shift bonus.”

What’s breaking down
But Ballad Health, which operates 21 hospitals (many in rural areas) across southwest Virginia and eastern Tennessee in Appalachia, can’t even consider mandating vaccine for its workers. News coverage in early October noted that less than two-thirds of Ballad Health’s staff had been vaccinated. While that’s higher than among the communities the health system serves (under 50%), its CEO worries that a vaccine mandate could drive away as much as 10% of its staff.

That’s completely untenable as the region slowly emerges from what Amit Vashist, MD, MBA, Ballad Health’s senior vice president and chief clinical officer, says was “devastation” from the delta variant for both the health system and its service communities. In early October, the Washington Post described the ferocious hit on Ballad Health’s nursing staff that successive covid surges have taken.

In that article, the health system’s chief nurse executive is quoted as saying that Ballad Health at the beginning of the pandemic was using fewer than 75 contract nurses to augment its hospital nursing staff. By this August, that number had exploded to 450, at rates as high as seven times what permanent hospital nurses in the system are being paid.

“We’re seeing much more patient violence.”

Brent Jackson, MD, MBA

~ Brent Jackson, MD, MBA
Dignity Health/Mercy General

According to Dr. Vashist, those parallel crises—the delta variant and not enough nurses—have had far-reaching effects beyond the health system’s bottom line. Elective surgeries throughout the system had to be suspended, as were transfers to the health system’s bigger hospitals.

“The hub-and-spoke model breaks down,” he says, “so hospitalists in outlying rural communities have to manage ICU-level patients without specialist support.”

Both the outbreak and the nursing shortage meant higher disease acuity and stress for hospitalists throughout the health system. And “all the strategies that help get patients out of the hospital—early ambulation, constant monitoring of central lines and catheters and telemetry—are a level of attention to detail that come only with appropriate nurse staffing,” notes Dr. Vashist. “But everybody’s stretched, it’s all hands on deck, and that creates bottlenecks in patient flow.”

Further, Dr. Vashist sees troubling implications in CDC data released this summer about the rise in the number of hospital-acquired infections in 2020, after years of steady decline.

“Look at quality scores around the country related to not only infections in the hospital, but falls,” he notes. “Both covid and staff shortages are affecting measures of hospital harm.”

Short- and long-term fixes
Vituity’s Dr. Miller points out that hospitalists swamped with covid who depend on daily morning team rounds find they can no longer round as a team.

“The nurses are too busy,” Dr. Miller says. “You can’t just re-engineer a system to adapt to a demand that exceeds capacity, especially when the people who would do that re-engineering are themselves overwhelmed with basic clinical work.”

Fortunately, he adds, hospitals have adopted some short-term fixes to help alleviate the shortage. When elective surgeries are suspended, for instance, OR staff can be redeployed to the floors. One hospital in which Vituity maintains a program was able to re-assign its scribes to at least offload some nursing tasks: taking vitals, transporting patients to imaging and answering family phone calls.

“We have an unrecognized problem in our country that we need to deal with, and it may be PTSD, particularly among front-line staff.”

Naznin-Jamal, MD

~ Naznin Jamal, MD
Jefferson Regional Medical Center

But, says Dr. Miller, what’s needed long term is to develop team nursing models. “Hospitals can use nonclinical staff to perform bedside tasks that don’t require an RN: food delivery, proning, answering phones or updating families,” allowing nurses to work at the top of their licenses. The challenge: Hospitals that are bleeding nurses are also losing techs, transporters and therapists. “They are all experiencing the same stressors as nurses,” says Dr. Miller, “and, similarly, are looking for better job opportunities.”

Developing new bedside team models is precisely how Dr. Zangerle with Allegheny Health Network is proceeding. Earlier this year, she started hiring licensed practice nurses (LPNs; also known as LVNs or licensed vocational nurses). Those are controversial hires, she points out, because hospitals for years have hired only nurses with bachelor’s-level degrees.

LPNs have instead gravitated to post-acute care, among other settings. But for several months, Dr. Zangerle has been piloting what she calls “blended nursing,” with LPNs and nursing assistants or patient care technicians working under RNs in bedside teams. That model has been rolled out in several units including med-surg and orthopedic units and rehab floors, with plans to implement it in EDs as well. According to Dr. Zangerle, LPNs now make up about 10% of her nursing workforce.

“It has been well-received on the units where we have gone full bore,” she says. “I can’t do it in every single unit because of patient acuity, and I’m OK with that. But I can send RNs to the units that need them and backfill with LPNs.”

The need for flexibility
Dr. Zangerle also points out that her state, Pennsylvania, sets no limit on the number of hours that hospital nurses can work; she thinks limits might not be a bad idea to help alleviate burnout. Long term, however, she believes hospitals have to transform how they approach nursing. “Agencies are forcing us to look at compensation—and not just trying to keep up with the market by raising the hourly rate by 50 cents,” says Dr. Zangerle. “We have to look at what’s fair.”

Hospitals also need to offer nurses what many have learned can help retain hospitalists: flexible schedules and part-time work. “For too long, it was all about what the hospital needed,” she points out. ” ‘You’ll work these 12hour shifts and every other weekend, or you won’t work at all.’ We can’t keep doing that.”

For Dr. Miller, one encouraging sign coming out of the pandemic is that nursing school enrollment is surging. In Pine Bluff, Ark., Naznin Jamal, MD, medical director of hospital medicine at Jefferson Regional Medical Center, points out that her hospital has access to a nursing school, “so we’ve been able to obtain quite a few.” Now coming down from the delta surge in her hospital, Dr. Jamal says the nursing shortage is still very real, but it’s no longer as desperate as it was during covid surges in 2020.

That’s when many bedside and ICU nurses in her hospital left for bigger hospitals—some in Little Rock—while others joined traveling nurse agencies. “Quite a few of them have since returned,” she reports. “But they haven’t returned to the hospital. Instead, they’ve taken an outpatient or administrative position.”

What bothers her, says Dr. Jamal, is that nurses who have gone through covid in the hospital are either leaving the profession or, at least, leaving inpatient care. To her, something else is at play than just business-as-usual supply and demand.

“I think we have an unrecognized problem in our country that we need to deal with, and it may be PTSD, particularly among front-line staff in the ED and the ICU,” she says. “I think it’s similar to what soldiers experience in war, and it’s an aspect of this pandemic that we’re not prepared for.”

In northern California, Dignity Health recently agreed to a new nursing contract that boosts nurse salaries by more than 13%. The agreement also includes enhanced benefits, infection prevention protection and tuition reimbursement.

And it includes more comprehensive workplace violence protections as well. Dr. Jackson at Mercy General points out that, even without his hospital being swamped by covid, “we’re seeing much more patient violence.” Some patients insist they don’t have covid or become angry because they’re not being prescribed ivermectin.

“The brunt of all of that,” he says, “falls on nurses.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Blended bedside teams

EVEN BEFORE the pandemic, Claire Zangerle, DNP, MSN, MBA, RN, chief nurse executive of Pittsburgh’s Allegheny Health Network, started thinking of bringing licensed practical nurses (LPNs) back into the hospital. As Dr. Zangerle explains, most LPNs had been phased out of acute care years ago in favor of RNs who have more education, training and scope of practice.

“We have to figure out how to make the bedside attractive again.”

Claire Zangerle, DNP, MSN, MBA, RN

~ Claire Zangerle, DNP, MSN, MBA, RN
Allegheny Health Network

But “our worst nursing shortage used to be in inpatient rehab, and we couldn’t find nurses with rehab experience,” she points out. That’s when she looked to outpatient rehab facilities and the LPNs they employed—and decided to introduce what she calls a “skilled mix change” in the rehab unit, with an LPN and a patient care technician working in a team under an RN.

“We could,” Dr. Zangerle says, “get two LPNs for an RN and a half.”

But then the pandemic struck with its widespread burnout, as did aggressive recruiting by travel nurse agencies. Still, when she announced that her hospitals—or at least some units—needed a new nursing care model to stretch their increasingly thin nurse staffing, her nurses pushed back.

“They were scared of LPNs, and they didn’t know what their scope of practice is,” she explains. “They also weren’t used to leading a team.”

Piloted this summer on certain units, the blended bedside teams have been very well-received. LPNs can administer medications, hang and start IVs, and help patients with activities of daily living and ambulation. Importantly, “LPNs can take care of a patient enough so that a nurse can actually take a break and have a meal,” Dr. Zangerle points out. “That’s not the case with nursing assistants.”

While it’s too soon to have real data on team outcomes, she reports that the teams seem to be boosting the number of early discharges, reducing length of stay and improving patient experience.

Still, bringing LPNs back into hospitals is, among nurse leaders across the country, “a taboo subject,” Dr. Zangerle says. “Some organizations say, ‘We’re not going to compromise quality by bringing LPNs back.’ ”

Her reply: LPNs can’t produce the same care quality as RNs because they don’t have the same scope of practice. But “what they do have is the ability to have work delegated to them by RNs,” she says. “Our nurses love the teams because they feel they have an extra set of hands and a colleague to work with, as opposed to being on their own.”

Published in the November/December issue of Today’s Hospitalist

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