Younger hospital nurses leaving the profession altogether

https://mailchi.mp/3390763e65bb/the-weekly-gist-june-24-2022?e=d1e747d2d8

The prevailing opinion earlier this year was that the hospital registered nurse (RN) shortage was being driven by older nurses retiring early or leaving hospital employment for less-demanding care settings during the pandemic. However, recent data shown in the graphic below paint a different picture. 

Hospital RNs with over ten years of tenure actually turned over at lower rates in 2021, compared to 2019. Meanwhile, the turnover rate for nurses with less tenure (who are typically younger) increased in 2021. While less-tenured nurses have always turned over at higher rates, we are seeing a new uptick in younger RNs leaving the profession

The size of the total RN workforce decreased by 1.8 percent between 2019 and 2021and the decline was twice as steep for hospital-employed RNs. Younger RNs disproportionately drove this decline: nurses under age 35 left the nursing workforce at four times the rate of those over age 50. 

A recent survey suggests younger RNs are less likely to feel their well-being is supported by their organization, and more likely to define themselves as “emotionally unhealthy.” To keep younger nurses in the profession, hospitals must increase the support available to them. Investments might include expanding preceptorship and mentorship programs, many of which were cut during the pandemic, and increasing behavioral health support and job flexibility.  

Travel nursing presents hospital employers with legal risks

The popularity of travel nursing is leaving healthcare facilities and the companies serving them susceptible to misclassification accusations and joint-employer disputes, Bloomberg Law reported June 14.

Providers should read contracts to understand who is liable if a travel nurse sues a healthcare facility and staffing company, according to the report. Even if agreements state that a hospital is not a temporary employee’s employer, courts may decide it’s a joint employer. If they are a joint employer, they may have to pay legal fees if a staffing agency is sued.

If classified as an employer, healthcare facilities may be bound by labor laws that didn’t apply to independent contractors. In California, for example, employers are required to pay part of a worker’s cell phone bill if a phone is needed for the job.

“Given the already serious issues with many of these healthcare workers feeling overwhelmed and underpaid, they’re going to turn these questions not just to the individual hospitals, but potentially also to the companies that are hosting these platforms,” Sonya Rosenberg, a labor and employment partner at Neal Gerber Eisenberg, told Bloomberg Law.

Read more here.

One-third of hospitals operating with negative margins & 6 other things to know

Hospitals and health systems have lost billions over the last two years, leaving more than 33 percent of them with negative margins, according to an April 25 report by the American Hospital Association.

Six findings:

1. Employment is down by 100,000 jobs compared to pre-pandemic levels, the U.S. Bureau of Labor Statistics found. But at a time when hospitals are desperately trying to fill positions, labor expenses per patient were 19.1 percent higher in 2021 than in 2019. Labor expenses are more than 50 percent of hospitals’ total expenses, meaning a small increase in labor costs can have a major effect on hospital’s total expenses and operating margins. 

2. The report attributed the increase in labor expenses to hospitals’ dependence on contract staff, specifically nurses. In 2019, travel nurses accounted for a median of 4.7 percent of hospitals’ total nurse labor expenses, compared to a median of 38.6 percent in January.

3. Hourly billing rates for contract employees rose 213 percent compared to pre-pandemic levels. This created a 62 percent profit margin for staff agencies.

4. Drug expenses soared by 36.9 percent per patient compared to pre-pandemic levels. 

5. Medical supply expenses also rose through 2021, by 20.6 percent, compared to pre-pandemic levels. For intensive care units and respiratory care departments — which were most involved in COVID-19 care — medical supply expenses grew 31.5 percent and 22.3 percent, respectively.

6. Economywide, the consumer price index saw major increases, the Bureau of Labor Statistics found. Meanwhile, hospital prices rose modestly, by an average of 2.1 percent per year in the last decade, about half the average annual increase in health insurance premiums. 

Snapshot Analysis Shows ‘Unprecedented’ Decline in RN Workforce

https://www.medpagetoday.com/nursing/nursing/98372?fbclid=IwAR0OCJM60DEXvvSlP48nqYbh7jIynIq0CrPNAB6rsFztxNQyb7oAyXnKOzc

The number of registered nurses plunged by 100,000 in 2021, representing the steepest drop in the RN workforce in 4 decades, according to a new analysis.

From 2019 to 2021, the total workforce size declined by 1.8%, including a 4% drop in the number of RNs under the age of 35, a 0.5% drop in the number of those ages 35 to 49, and a 1.0% drop in the number of those over 50, reported David Auerbach, PhD, of the Center for Interdisciplinary Health Workforce Studies at Montana State University College of Nursing, and colleagues in Health Affairs Forefront.

“The numbers really are unprecedented,” Auerbach told MedPage Today.

“But … given all that we’ve been hearing about burnout, retirement, job switching, and shifting,” and all of the ways the pandemic disrupted the labor market, including healthcare, “I am not super surprised either,” he added.

While Auerbach said he and his co-authors can’t definitively say what caused this shift, he does not think it’s merely a problem of “entry and education” — in other words, fewer people choosing nursing as a career.

There have been no “major changes” in the enrollment and graduation rates reported by the American Association of Colleges of Nursing (AACN), and the number of RNs completing the National Council Licensure Examination actually increased in 2020 versus 2019, according to the National Council of State Boards of Nursing, Auerbach said.

This suggests that the decline in younger RNs is more likely due to nurses “either pausing or leaving nursing. What we really don’t know is whether this is a temporary or more permanent phenomenon,” he added.

The overall decline was not spread evenly across sites, but instead was “entirely due” to a 3.9% reduction in hospital employment, offset by a 1.6% increase in nursing employment in other settings, the authors said.

For decades, the RN workforce grew steadily, from 1 million nurses in 1982 to 3.2 million in 2020. Though the profession saw a rocky period in the late 1990s, during which growth looked less certain, millennials reversed this temporary downward trend in the early 2000s, Auerbach and team explained.

In a prior Health Affairs analysis, Auerbach and colleagues found that the labor market for nurses had “plateaued” during the first 15 months of the pandemic.

Auerbach’s team had previously projected that the supply of nurses would grow 4.4% from 2019 to 2021.

The data may reflect a mix of RNs leaving “outright” and those shifting to non-hospital jobs. The authors were unable to follow the same people from pre-pandemic to now, Auerbach noted. “Based on taking a snapshot of the world in 2019 and then taking another snapshot of the world in 2021, we’re inferring from what we see what we think might have happened.”

Auerbach said that he and his colleagues are close to ruling out childcare problems as a core reason for younger nurses departing. “We didn’t see some huge reduction in nurses with kids at home,” he explained.

However, if that had been the case, then the decline might be seen as something temporary that could be “ironed out,” compared to more deeply rooted structural problems, like poor working conditions, he said.

Auerbach and colleagues stressed that more needs to be done to help early-career nurses who have endured a “trial by fire” during the pandemic, and that “more effective strategies” must be leveraged to reward nurses who have stayed on the front lines and to bring back those who have left.

On a hopeful note, Auerbach pointed to recent AACN data, which showed a “big jump” in the number of applications to nursing schools. Additionally, prior research found that “times of natural disaster or health crisis could increase interest in RN careers,” the authors noted.

“That doesn’t sound like people are just going to abandon nursing altogether,” Auerbach said.

Sutter Health: Nurses who staged 1-day strike must wait 5 days to return to work

Sacramento-based Sutter Health said nurses who went on strike April 18 will not be allowed to return to work until the morning of April 23, the San Francisco Chronicle reported.

The strike affected nurses and healthcare workers at Sutter Health facilities in Northern California. The nurses are members of the California Nurses Association, and the other workers are members of the Caregivers and Healthcare Employees Union, an affiliate of the California Nurses Association.

More than 8,000 registered nurses and healthcare workers were expected to participate in the strike, according to an April 18 news release from the unions.

In a statement shared with Becker’s, Sutter Health said the organization conducted strike contingency planning, which included “securing staff to replace nurses who have chosen to strike, and those replacement contracts provide the assurance of five days of guaranteed staffing amid the uncertainty of a widespread work stoppage.” 

“As always, our top priority remains safe, high-quality patient care and nurses may be reinstated sooner based on operational and patient care needs,” the statement said.

The California Nurses Association described Sutter Health’s decision as retaliatory, as well as “completely unnecessary and vindictive.”

“Nurses who are regularly scheduled to work during this lockout period will lose those days of pay,” the union said in a statement shared with Becker’s. “We urge Sutter to respect the nurses’ strike and let all nurses return to work.”

Sutter Health workers authorized a strike in March, and union officials announced an official strike notice April 8. Union members cited lack of transparency about the stockpile of personal protective equipment supplies and contact tracing as a reason for the strike. They also said they seek a contract that will help retain experienced nurses and provide sufficient staffing and training.

Nurses have been in contract negotiations since June. 

Don’t pin your hopes on the “Great Regret”

Businesses who suffered from the Great Resignation, in which large numbers of workers voluntarily resigned during the pandemic looking for more fulfilling work or higher wages, are now hoping the “Great Regret” might bring workers back. According to recent surveys, over 70 percent of workers who switched employment during the pandemic found that their new jobs didn’t live up to their expectations, and nearly half wish they had their old job back.

After scores of nurses left hospital positions for travel roles, health system leaders are seeing some nurses return. One physician told us about a favorite nurse on his oncology unit who returned from over a year as a traveler, ready to settle down and be closer to family.

A chief nursing officer relayed that her system was seeing nurses who took agency positions to work toward personal financial goals, like earning a down payment for a house, wanting to come back now that they’ve reached it: “Travel roles are intense, and most nurses can’t do them forever”.

But other nursing leaders caution that they’re preparing for agency nurses to become a permanent fixture in the workforce: “More nurses will see travel as an option for different points in their career, when they have personal flexibility or need the extra money”.

The “Great Regret” might help some hospitals lessen their reliance on agency nursing in the short-term. But building a stable clinical workforce will require addressing underlying structural challenges, through changes in education, rethinking job roles and care models, and finding ways to build individualized job flexibility and customization.   

Why don’t hospitals just pay full-time nurses more?

Hospitals’ reliance on travel workers is nothing new. The pandemic intensified it and highlighted the gap between full-time workers’ pay and lucrative temporary contracts. 

While the average salary for a travel nurse can vary based on location, regional demand, hospital type and specialty, the compensation for a travel nurse has increased significantly compared to pre-pandemic, Bill Morgan, president of the Orlando, Fla.-based travel nurse staffing firm Jackson Nurse Professionals, told Becker’s in September. 

Meanwhile, hospitals and health systems have offered bonuses, increased wages and made other investments in employee retention for their staff workers. Still, the compensation gap between hospital employed nurses and travel or agency nurses remains stark. 

The gap poses the seemingly simple question: Why aren’t hospitals paying full-time staff more instead of paying higher prices for travel workers? 

Travel nursing’s start 

Taking a look back at the history of why hospitals started using travel nurses in the first place helps answer that question, said Kathy Sanford, DBA, RN, chief nursing officer at Chicago-based CommonSpirit Health. 

Dr. Sanford recalls first using local agencies and travel nurses in the 1980s as a cost-effective staffing strategy for periods when the patient census fluctuates, such as during flu epidemics. 

“When you have those fluctuations, you need to have a staffing strategy of what you want to do when the census goes up higher than we are staffed for, but it’s only going to last maybe a month, or a little longer,” she told Becker’s. “Because of the fluctuations, our nursing strategy for staffing was to use these non-employed nurses to fill in when there were gaps.” 

The COVID-19 pandemic, however, has created a situation where volumes are consistently higher than normal. And while rates for a travel or agency nurse have traditionally been higher than those of a hospital staff nurse, the current demand has pushed travel rates to record highs. 

Rising rates

Pittsburgh-based UPMC, for example, paid an estimated $85 an hour for a traveling nurse or a nurse from an agency before the pandemic. The health system is now experiencing rates between $225 and $250 an hour. Such rates have made nurses who may not have considered traveling before take the leap. 

“And the nurses are making more, and we don’t fault the nurses for taking advantage of that opportunity. But … now not only are nurses making more, but the agencies have taken the opportunity to triple their profits … and it shouldn’t be permitted during a pandemic, just like we don’t permit building companies to triple the price of lumber after a hurricane. It just shouldn’t be allowed,” said John Galley, chief human resource officer at UPMC. 

“Hospitals are all trying to fill the positions that need to be filled to help us get through this crisis with travel nurses, but because there aren’t enough, it becomes a cycle of bidding of who will pay me the most to travel,” Dr. Sanford said. Because of that, many nurses who may have never considered traveling before are now choosing to do so and leaving hospitals in areas of the country with a lower wage index, she said. 

Pay for travel nurses has always been higher for the same reasons hospitals pay float pool nurses more, Dr. Sanford explained. 

“Nurses are specialists and they work on a particular type of unit, and sometimes one unit’s census will be down and another unit’s census will be up,” she said. Float pool nurses are willing to shift to different units that need help “and it’s not a favorite thing for nurses to do,” Dr. Sanford said. “You have to pay them a little extra to be willing to learn different types of nursing and be willing to float.” 

The same line of thinking applies to agency or travel nurses. Travelers don’t have the perks that come with a full-time job, like job security and benefits. That coupled with the burden of travel itself and short-term assignments was the initial justification for why travel nurses had higher rates. 

Simply put, hospitals can’t afford to pay full-time staff wages that were meant for temporary assignments. 

“The bottom line is it would not be sustainable for hospitals to pay the kind of dollars that they’re paying right now for travel nurses in the long run. Because nurses are our backbone … they’re our heart, but they’re also our backbone. They’re the majority of our staff.” Dr. Sanford said. 

Mr. Galley of UPMC echoed that sentiment, noting that salaries and benefits make up about 50 percent of a health system’s entire expenses. “If you were to double a good portion of that — the nursing salaries — you’d completely wipe out any operating margin. Then you wouldn’t be able to invest in anything to keep the hospitals going,” he said. 

And healthcare has a lot of costly demands that would go unaddressed if such rates became the expectation for staff nurses. 

“There are a lot of needs that healthcare has in technology, and making sure that we have the equipment to take care of patients, and that we can do programs for the poor and vulnerable that we wouldn’t be able to afford if we pay these non-sustainable prices forever,” Dr. Sanford of CommonSpirit said. 

The value of in-house agencies

To combat skyrocketing travel nursing costs, some health systems have introduced their own travel agencies, including CommonSpirit and UPMC, where travel nurses work within the system.

Mr. Galley said UPMC started the agency for its 40-hospital system not only to combat the nursing shortage — and attract back nurses the health system has lost to outside travel agencies — but also to address increased rates from outside travel agencies. 

Nurses and surgical techs who qualify for UPMC’s in-house agency will earn $85 an hour and $63 an hour, respectively, in addition to a $2,880 stipend at the beginning of each six-week assignment.

Compensation for travel nurses at UPMC is still higher than full-time employees because the job comes with its own set of challenges. While full-time nurses get to know their facilities and have a more regular schedule, travel nurses are constantly on the move.

“They’re going to have assignments for a few weeks at a time at a particular location, then we’re going to pick them up and move them somewhere else, so they’re going to be constantly traveling, living out of a suitcase, and that’s what external travelers do, so we want to be just like the market, create roles like that and pay like that,” Mr. Galley said. “I think our employees understand the difference between that kind of a lifestyle that goes along with the higher salary.”

CommonSpirit’s internal agency plans to start traveling in the early spring and is in the process of hiring a national director for the program. The system’s goal is to have 500 nurses.

Dr. Sanford said the program will be beneficial because it will bring down competition, and people who want to travel can still be employees within the health system.

“It gives nurses who are our employees a choice if they want to be travelers or if they want to do it part time and then come back to a job within one of our hospitals or in one of our clinics. … They won’t lose their benefits, they won’t lose their seniority. They’ll be our employees,” Dr. Sanford said.

Other systems are exploring similar programs, such as Charlotte, N.C.-based Atrium Health, which recently ran a pilot in-house traveler program. The health system has also used outside agencies, which cost about triple compared to pre-pandemic.

This program was very successful, less expensive than using an external travel agency and worked really well across our large health system that covers multiple states,” said Patricia Mook, MSN, RN, vice president of nursing operations at Atrium Health.

But internal travel programs may not be easy for other health systems to mimic, especially smaller ones. Hospitals have to be of a certain size for an internal travel program to work, meaning an individual hospital wouldn’t be able to have one, Mr. Galley said.

More than that, it’s a complex undertaking, he said. 

“It’s not without its challenges,” Mr. Galley said. “I just think it’s something that takes the resources and thought leadership to be able to do. But you’re not going to find independent hospitals being able to mirror this.”

Dr. Sanford also recommends having a few different strategies in place to combat nurse shortages.

“Don’t make it your only strategy because there are so many issues that we could do better with our nursing staff. … You need to be looking at all of the different things that give nurses voice in your organization,” Dr. Sanford said.

More than 4K Stanford nurses vote to strike in California

UPDATE: April 14, 2022: Nurses will begin striking April 25 if they are unable to reach a deal with the system by then, according to a Wednesday statement from the union. The two sides have met with a federal mediator three times, and the strike would be open-ended.

Dive Brief:

  • Unionized nurses at Stanford hospitals in California voted in favor of authorizing a strike Thursday, meaning more than 4,500 nurses could walk off the job in a bid for better staffing, wages and mental health measures in new contracts.
  • Some 93% of nurses represented by the Committee for Recognition of Nursing Achievement voted in favor of the work stoppage, though the union did not set a date, according to a union release. It must give the hospitals 10 days notice before going on strike.
  • Nurses’ contracts expired March 31 and the union and hospital have engaged in more than 30 bargaining sessions over the past three months, including with a federal mediator, according to the union.

Dive Insight:

As the COVID-19 pandemic has worsened working conditions for nurses, some unions have made negotiating contracts a priority. Better staffing is key, along with higher wages and other benefits to help attract and retain employees amid ongoing shortages.

The California nurses’ demands in new contracts focus heavily on recruitment and retention of nursing staff “amid an industry-wide shortage and nurses being exhausted after working through the pandemic, many in short-staffed units,” the union said in the release.

They’re also asking for improved access to time off and more mental health support.

Nurses say their working conditions are becoming untenable and relying on travel staff and overtime shifts is not sustainable, according to the release.

The hospitals are taking precautionary steps to prepare for a potential strike and will resume negotiations with the union and a federal mediator Tuesday, according to a statement from Stanford.

But according to CRONA, nurses have filed significantly more assignment despite objections documents from 2020 to 2021 — forms that notify hospital supervisors of assignments nurses take despite personal objections around lacking resources, training or staff.

And a survey of CRONA nurses conducted in November 2021 founds that as many as 45% were considering quitting their jobs, according to the union.

That’s in line with other national surveys, including one from staffing firm Incredible Health released in March that found more than a third of nurses said they plan to leave their current jobs by the end of this year.

The CRONA nurses “readiness to strike demonstrates the urgency of the great professional and personal crisis they are facing and the solutions they are demanding from hospital executives,” the union said in the release.

No major strikes among healthcare workers have occurred so far this year, though several happened in 2021 and in 2020, the first year of the pandemic.

Rising turnover, agency costs compound hospital labor problems

Even as COVID admissions continue to wane, hospitals report that workforce shortages persist. The impact on hospital finances is stark: as shown in the graphic above, there has been an eight percent increase in clinical labor costs per patient day since the start of the pandemic, amounting to an additional $17M annually for an average 500-bed hospital. 

Two of the primary factors driving this increase—higher turnover among clinical staff and a continued reliance on travel nurses—are mutually reinforcing. 

Quarterly turnover rates for some nursing positions doubled from Q4 2019 to Q2 2021, as hospitals turned to expensive agency labor to fill resulting vacancies. Spiking demand for travel nurses, still running nearly three times higher than the pre-pandemic baseline, fueled more turnover, as more nurses left for these lucrative roles. 

It’s unclear how long increased labor costs will persist

Some HR tactics, like signing and retention bonuses, are one-time expenditures. But total hospital employment is still down two percent from pre-pandemic levels, pointing to a diminished healthcare labor supply. 

Permanent wage increases may end up being unavoidable, especially for lower-wage jobs, where a new compensation baseline for talent is being set by the market, both inside and outside the healthcare industry. 

Tennessee nurse convicted of negligent homicide for fatal medication error

A jury found former Vanderbilt Health nurse RaDonda Vaught guilty of negligent homicide and gross neglect of an impaired adult after she committed a fatal drug error in 2017. Vaught, who gave a patient a lethal dose of the paralytic agent vecuronium rather than the sedative Versed, overlooking several warning alerts, now faces up to six years in prison.

The Gist: Criminal charges for unintentional medical errors like this one are very unusual; discipline is normally the purview of licensing boards and civil courts. While Vaught certainly made an egregious mistake that directly led to a patient’s death, there’s a delicate line between holding caregivers accountable and making them criminally liable for unintentional errors. 

The American Nurses Association warns this verdict could set a dangerous precedent, and have a chilling effect on providers’ reporting errors. Health systems have worked diligently over decades to promote a culture of quality improvement and transparency—central to that is an environment that encourages providers to report all medical errors in order to improve patient safety. Many providers are now concerned that this conviction could reverse that progress.