THIS MAY, BSA Health System in Amarillo, Texas, held its first-ever signing ceremony, the type of event usually reserved for athletes when they agree to play for a college or professional team. But this ceremony was for the 65 nurse graduates from local programs signing on to work in BSA facilities.
Those new nurses will go a long way toward repairing “the horrendous turnover” her health system experienced during the pandemic, says hospitalist Sheryl Williams, MD, medical director of quality at BSA Hospital. “This is a huge bolus for us. It’s really going to help us out.”
Around the country, hospitals are hiring—and they are particularly keen to replace the nurses who made a mass exodus out of inpatient care. How keen can be measured by this recent news item: In April, a health system in southern California was offering currently employed and new-hire RNs a $100,000 signing bonus if they committed to working full-time for three years.
In Amarillo, Dr. Williams says the new hires will undergo “weeks and weeks of orientation, shadowing and working in tandem with senior nurses. It’s very rigorous.” But the fact that a new generation of nurses nationwide is now replacing those who spent decades on the floors means that doctors are increasingly working with nurses who need to build familiarity and skills.
Read related article: How comfortable are you giving nurses feedback?
New, travel hires
Ballad Health, a 21-hospital regional health system serving parts of Appalachia, has also been able to recruit, says senior vice president and chief clinical officer Amit Vashist, MD, MBA.
“We’ve hired a lot of international nurses from parts of Africa and southeast Asia,” Dr. Vashist says. While those nurses “have a superb knowledge base, cultural differences as well as their proficiency in English and in the slang we use in everyday medical jargon are some initial issues.” He adds that the nurses were “very quick to pick those up.”
“New nurses need hands-on training, and it takes them some time to develop that psychological safety.”
Amit Vashist, MD, MBA
“We have a mix of very high-quality nurses who have been here for years and those who are inexperienced,” says Jeremy Jaskunas, MD, a hospitalist at UnityPoint Health-Meriter Hospital, a community teaching hospital in Madison, Wis. “While it has definitely changed the clinical work environment for the nurses, it has for doctors as well.”
Then there are “the very newbie nurses,” he points out. “Many trained predominantly online during the pandemic, so they aren’t as well-versed in protocols, how to do daily dressing changes and who to call to express concern. New nurses need hands-on training, and it takes them some time to develop that psychological safety.” Challenges now with staff “depend on which kind of nursing staff you’re dealing with.”
Dr. Vashist mentions this upside: His system’s expensive pandemic reliance on travel nurses has waned. In fact, he and his colleagues are seeing some nurses who left for lucrative travel positions return.
But many hospitalists around the country say that travel nurses continue to be a big presence in their hospitals. While travel nurses may arrive with a lot of bedside skills, they—like new hires—aren’t familiar with medical staff or local protocols.
Moreover, rapid turnover among travel staff makes it tough to get used to working with each other as a team. For many hospitalists, adjusting to either travel nurses or new hires or both is now the new normal—and they know it and it may take years before they’re again working with a consistent pool of people.
Unusual orders, disruptive patients
Even years may not put an end to the revolving door, according to Jeremiah Anders, MD, medical director of the hospitalist program at OSF HealthCare Saint Francis Medical Center in Peoria, Ill., the largest facility in the 15-hospital OSF HealthCare system.
While Dr. Anders is relieved to see staffing at his hospital begin to approach pre-pandemic levels, he suspects that the new nurses now at the bedside won’t stay there long. “Stipends have dropped dramatically since the peak days of the pandemic,” says Dr. Vashist, “and people want to work closer to home.”
“Younger, engaged nursing staff have more interest in expanding their career opportunities than in ramping up bedside experience.”
Jeremiah Anders, MD
OSF HealthCare Saint Francis Medical Center
“Younger, engaged nursing staff have more interest in expanding their career opportunities than in ramping up bedside experience,” he says.
“I see them transitioning to APP training earlier and earlier in their careers.” Where nurses entering APP training once had years of experience behind them, that’s no longer the case. “That speaks to the demand.”
Dr. Anders also notes that working in a 620-plus-bed hospital makes it that much harder to figure out who’s a travel nurse and who’s a new hire.
And “we don’t know what we don’t know,” he points out, meaning that hospitalists don’t have a good handle on which skills for which nurses are a work in progress. “We now need to be very intentional about discussing unusual orders, and we can’t drop a series of orders for ACTH stim tests or 16 STAT orders and run away without talking to the nurse about them. But we may not know to do that.”
Dr. Jaskunas at UnityPoint Health-Meriter Hospital agrees. “Nurses do a lot more than just following orders and passing medications,” he says, skills that include running interference for physicians and performing clinical assessments. “Hospitalists don’t appreciate how often nurses do all these things until we work with nurses who don’t.”
One example is managing the behavior of disruptive patients. “Nurses’ experience or lack thereof in handling such patients plays a huge role,” Dr. Jaskunas notes. His hospitalist group has the good fortune to have a health psychologist embedded in the program.
“Communication has to include other specialties.”
Wes Chandler, MD
Pacific Hospitalist Associates
“She coaches up nursing on setting boundaries and dealing with harassment or aggressive behavior,” Dr. Jaskunas says—but that coaching takes time. He increasingly finds himself responding to behavioral emergencies where all the nurses and security team members now expect him, not the nurse, to take the lead.
“Everyone is looking to the doctor, thinking the white coat might have more pull with patients or families, but I wasn’t trained to deal with disruptive patients,” he says. The fact that the situation keeps happening is a measure of how many seasoned nurses are no longer there.
Texts and messages
Perhaps the biggest adjustment to working with inexperienced nurses is the exploding volume of calls/ texts/”chat” messages.
That’s the case at Hoag Hospital Newport Beach. “The younger and newer nurses don’t know the physicians, including the consultants,” says Wes Chandler, MD, president of Pacific Hospitalist Associates, a private group in southern California.
The high message volume “is leading to more physician burnout, lower hospitalist productivity, and longer days and nights,” he says. One particularly egregious example: A nurse who didn’t know where to locate the list of on-call physicians texted 27 different hospitalists, including those who work days and some who work nights at two separate hospitals, looking for the hospitalist on call.
One problem, Dr. Chandler explains, is that the hospitalists have been using a secure texting app with nurses for the past year—one the other specialists refused to use.
“Time invested now in education is time saved later.”
Jeremy Jaskunas, MD
UnityPoint Health-Meriter Hospital
“No consultants wanted to give nursing direct texting access, so hospitalists now get all the arrhythmia reports when there’s a cardiologist on the case and questions about what patients can eat after GI surgery,” Dr. Chandler says. “Nurses even text us with, ‘Have you seen Dr. Surgery? He’s not responding to my calls.’ ”
To rein that in, the doctors formed a physician communication committee to provide feedback and instruction to nursing. “So far, we have not noticed improvement.” Their next move: Switching from the communication app they’ve been using to Epic Secure Chat. “Nurses will at least be able to reach consultants,” he says. “Communication has to include other specialties.”
At his hospital, Dr. Jaskunas says that Epic Secure Chat replaced all phone calls and pages at the beginning of the year. As he reports, “the number of texts we’re getting from inexperienced nurses is overwhelming” and often reflects the underlying anxiety of those new to the job. “It sometimes feels like we not only have to manage patients but the anxieties of inexperienced staff as well.”
When responding, “you want to spend some time explaining your thought process because time invested now in education is time saved later.” While a thoughtful response is sometimes enough, he at other times goes to the bedside to help clear up any issues—a process that “without a doubt” now adds at least an hour to his work day.
What helps, says Dr. Jaskunas, is to hold informal multidisciplinary rounds with bedside nurses as often as he can.
“When I’m rounding and I know that nurses have my patients, I grab them and say, ‘Do you have time to come in with me?’ ” he says. “Each conversation we have together erases the need for 20 secure chats.” Unfortunately, the pandemic put an end to his hospital’s practice of holding morning huddles, which included bedside nurses. That innovation hasn’t been revived.
Other hospitalists say that pre-rounding—going to the floor early to speak with nurses about individual care plans, giving them a chance to take notes to serve as that day’s “cheat sheet”—also saves time and cuts down on texts or pages. Some hospitalists also circle back in the afternoon to make sure that “pending” items mentioned in the morning have been taken care of.
In Peoria, Dr. Anders used to hold “lunch and learn” sessions before the pandemic, including after-hours sessions for the night staff. Those sessions covered when to call the hospitalists, what information to have ready and how to batch messages so doctors won’t be constantly interrupted.
One strategy Dr. Anders recommended in those sessions was to first run questions by a charge nurse to filter out those that doctors didn’t need to handle. But given that charge nurses now are being promoted more quickly, they often don’t have the years of bedside experience they once had, Dr. Anders says. And with short-staffing, charge nurses often fill in as bedside nurses themselves.
“They’re not really able to function as a charge nurse,” he says. “They don’t have the same ability to provide mentorship and leadership.” Still, he plans to find the PowerPoints he once used and hold those sessions again.
That raises another issue, Dr. Anders points out: When something clinical is missed or needs to be redone, “hospitalists don’t do a good job providing that feedback” to either the nurse involved or to him as hospitalist medical director so he can discuss it with a nursing manager or director.
“I’m not talking about some horrific outcome,” Dr. Anders explains, “but something where there’s an education gap on either side.” Instead, hospitalists “have a very short memory and move on to the next scenario,” so the potential education and skill-building that’s needed is missed.
While Dr. Jaskunas hopes that physicians and nurses will at least work together to hammer out ground rules for communications, he’s not seeing coordinated efforts to do so.
Instead, he and his colleagues “just stay at work that much longer. I find that physicians think, ‘I’m just going to tough it out and get home an hour later.’ ” Unfortunately, “toughing it out” has contributed to the large number of clinicians who have left the hospital, if not the profession.
“You hope we can work together to find solutions rather than just getting up and leaving,” says Dr. Jaskunas. “That’s what nurses have done, and now doctors are doing the same.” In the face of long-standing staffing shortages and this sea change of transitions, he hopes to see physicians and nurses collaborate on problem-solving “rather than just moving on.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Published in the July/August 2023 issue of Today’s Hospitalist.