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As stressed nurses leave, challenges endure to replace them

Katie Tabeling
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Delaware Nurse at Bayhealth, 2023. | PHOTO COURTESY OF BAYHEALTH

Nurses across the country are leaving the bedside, either to become “travel nurses” or the profession entirely. State experts weigh in on how that is playing out in Delaware – and what can be done. | PHOTO COURTESY OF BAYHEALTH

The current nursing shortage isn’t an overnight issue. For years, Delaware nurses have been retiring while education programs sometimes struggled to find space to accept rising nurses to fill their ranks. The COVID-19 pandemic just shined a brighter spotlight on it.

“There’s been workforce challenges for decades, with ebbs and flows, and the public health emergencies have exacerbated underlying issues we’re seeing. Not to sound doom and gloom, but it will get worse before it gets better,” Delaware Nurses Association Executive Director Chris Otto said. “Nurses are true caregivers, and they give everything they get. But they’re choosing to leave certain settings that give them less stress and more flexibility.”

In 2021, 3,791 nursing licenses in Delaware were not renewed, according to a report from the Delaware Academy of Medicine/Delaware Public Health Association. That timeframe also captures Delaware nurses who left the bedside during 2020, when many health care professionals were expected to continue front-line jobs without an available COVID vaccine. Other emotional stressors, like being with COVID patients as they struggled without admitting visitors, also took a toll.

But even before the pandemic, Delaware saw 3,226 nursing licenses expire in 2019. The report also shows that 1,194 Delaware nurses, of all license types, were of retirement age. While the report does not detail how active these nurses are in the field, it shows the “silver tsunami” in the profession. 

The data for 2021 can be misleading, as Delaware joined the National Nurse Licensure Compact in August 2021. The state has yet to determine how many non-renewals are due to the important change in nursing licensure – – as Delaware nurses could be registered here  and travel to work in another state, and vice versa.

While travel nurses have become a hot topic as a temporary stop-gap for the shortage for contracted time periods, Otto hears it’s less about the money and more about what that profession can offer.

“Pay is a big draw when we do talk to travel nurses, but there are other reasons why they made that decision. One of them is that autonomy over their schedules and work-life balance,” Otto said. “There’s less requirements that may make it harder to juggle family or personal priorities. It’s why our association is working with health systems to really focus on retention strategies and place higher value on that.”

The cost of labor

With more Delaware nurses leaving the bedside, it’s putting more pressure on those who stay behind to pick up more shifts. At an October roundtable at Beebe Healthcare with U.S. Rep. Lisa Blunt Rochester (D-Del.), Black Nurses Rock Delaware Chapter President and CEO Nishelle Harris-Hines said that during the early years of the pandemic she saw health care systems start assigning additional shifts to those who stayed after others left.

“One of my clinical jobs told me they needed me to be on call for three [12-hour] shifts. But when someone didn’t sign up, they gave me four. Then I was told I had to work two holidays, a winter and a summer,” Harris-Hines said in late October. “At my other job, if I had to work a winter or a summer, I’d have no holidays. As much as I wanted to stay and help, it wasn’t easy to do.”

Nationally, the registered nurse year-over-year turnover rate grew by 8.4%, bringing to the national average to 27.1%, according to the 2022 NSI National Health Care Retention & RN Staffing Report. Each percentage point change in nurse turnover costs or saves the average hospital $262,000 per year, officials estimated.

When the seasoned staff leave, it also creates a vacuum of institutional knowledge. Who is left to train the new nurses as they start their careers?

Delaware Nurse at Bayhealth, 2023. | PHOTO COURTESY OF BAYHEALTH

The COVID-19 pandemic has exacerbated the nursing shortage, but industry leaders in Delaware stress, it’s been going on for years before the pandemic – and having enough nurse
educators is also becoming a problem. | PHOTO COURTESY OF BAYHEALTH

Working to fill the openings

ChristianaCare officials told Delaware Business Times that it has 400 nursing positions open as of Jan. 10. 

The cost of labor, including increased use of travel nurses, is one of the significant drivers in increased expenses – and travel nurses have been relied upon in the past two years during the pandemic and in the tight labor market, according to ChristianaCare Chief Nurse Executive and HomeHealth President Ric Cuming. 

But ChristianaCare, Bayhealth and others have offered recruitment, sign-on and referral bonuses. At ChristianaCare, Cuming noted that their recruitment team had been “hiring nurses in record numbers.”

Other initiatives, like the Center for WorkLife Wellbeing at ChristianaCare, and using innovative technology like robots to perform low-level tasks and using Amazon Alexa to support postpartum patient rooms also helps support the caregivers.

“We put our caregivers first, because we believe putting our caregivers first allows them to put their patients first,” Cuming said. “These investments have paid off. At the height of the pandemic, when health systems were desperately competing for staff, our turnover rate was below the national average.”

Nemours Children’s Health, which sees most of the medically complex pediatric patients in the state, often requires hiring the most highly trained nurses. But Nemours Senior Vice President and Chief Nursing and Patient Operations Officer Aaron Carpenter said that the recent uptick in respiratory viruses have exacerbated nationwide hiring and retaining staff at children’s hospitals across the country.

“Nemours invests heavily in nursing training programs including an RN Residency Program, an Evidence-Based Practice Fellowship, a Student Nursing Advancement Program and more,” Carpenter said. 

Nemours said that turnover improved more than 50% in the past 12 months, works with current nurses to determine needs and outline job descriptions and schedules that are a beneficial fit.

Beebe Healthcare also uses contracted workers to “supplement its workforce and to be able to respond to the growing community and our patient needs,” according to officials. But recently, the Sussex County health care system said it has reduced contract staff as hiring has picked up in inpatient and outpatient settings, due to heavy recruitment and offering competitive sign-on and referral bonuses.

Beebe has also hired a full-time recruiter, as well.

“We’ve been really encouraged by the efforts during the past few months to onboard clinical team members and grow our staff to serve the growing community in Sussex County,” Beebe spokesman Ryan Marshall said,

In the classroom

The “silver tsunami” isn’t just a wave of Delaware nurses, it’s also nurse facility members. University of Delaware School of Nursing Chief Academic Officer Elizabeth Speakman argued that could be a greater pain point when it comes to addressing the workforce shortage.

“When people suggest we ‘just graduate more nurses,’ they often do not realize the problem is twofold. Simply put, there is a nurse faculty shortage as well, until we attend to both issues, the nurse shortage is not going away,” she said.

For example, she said that UD School of Nursing has capacity for about 170 students but receives about 2,500 applications. Some of those applications may be duplicates, but still, Speakman pointed out that many are turned away. With fewer faculty, there are fewer opportunities for clinical experience to provide hands-on training.

Nursing schools across the country turned away 91,938 qualified applications (not total applicants) in graduate nursing programs in 2021, according to the American Association of College of Nursing.

One of the universal disadvantages to attracting faculty is pay. The average salary of a registered nurse in Delaware last year was $37,390, according to the state Department of Labor, but overtime routinely brings in thousands more. Delaware nurses who go into academia face a pay cut and requirements to get a master’s or doctorate degree – compared to a nurse with a bachelor’s degree who can earn overtime.

“I think nurses choose to become educators because they have a true belief, much like all nurses do, that being a nurse educator is about having an impact on the individuals we serve.  Being a nurse educator has been a wonderful career and it’s something I’m proud of,” Speakman added. “But until there is a concerted effort to deal with the nurse faculty shortage and recognize that nurse educators are retiring at a fast pace then they are being replaced we will not be able to impact the nurse workforce.”

A Delaware Academy of Medicine/Delaware Public Health Association survey of five nursing education institutions reported that two turned away students due to staffing shortages. Those five institutions also anticipated a range of 14 to 20 faculty retirements in the next two years.

Long-term solutions?

In the First State, health care leaders, associations, educators and legislators are actively working on solutions to find ways to address retaining and recruiting Delaware nurses. For example, ChristianaCare received $2.4 million in American Rescue Plan Act funds to expand education efforts throughout the state, including in southern Delaware and underserved areas in Wilmington.

Meanwhile, Rep. Blunt Rochester is pushing the Biden administration to outline a coordinated national strategy to address the shortage in the Fiscal Year 2024 budget. She also is advocating for the National Nursing Workforce Center Act, which she introduced in September.

That bill would establish a three-year pilot program to “support state-based nursing workforce centers” by looking at real-time data and working with hospitals, nursing homes and other facilities to address recruitment and retainment issues.

“In the face of the COVID-19 pandemic, the already overstretched nursing workforce is being forced to grapple with a host of new and intensifying challenges that now threaten the stability and quality of the care system,” Blunt Rochester wrote to the Office of Management and Budget in December. “While the Biden administration has worked tirelessly to support the nursing workforce, it is now abundantly clear that improved federal and state coordination is needed to monitor nursing shortages, coordinate strategies and advise policymakers, health care leaders, and educators.”

Making education more affordable for Delaware nurses to up-skill would also help both the educator shortage and open up class sizes for more students. Some existing programs are looking at being revamped, such as the state’s health care provider loan program, which offers up to $50,000 in annual loan forgiveness for up to four years for those who stay to practice in underserved areas in Delaware. But with only two applicants for the latest round, the state Health Care Commission has opened discussions on possibly opening it to established physicians and Delaware nurses who have practiced for at least a year.

Speakman, who has held senior leadership positions at universities in New Jersey and Pennsylvania including at Thomas Jefferson University, said that one thing that makes Delaware stand out is the ongoing collaboration efforts among higher education and clinical partners.

She and colleagues in Delaware are working on an application with the U.S. Department of Labor to possibly fund scholarships for Delaware Technical Community College nursing students to UD’s nurse educator program. At the same time, other academics in the state are working with clinical partners to examine curriculum and sharing information of what works and doesn’t work.

“If changes are going to occur, it’s going to occur in Delaware,” she said. “In Delaware folks from education and practice as well as key legislators are working together as a team to develop strategies to combat the nursing shortage. It’s this common mission and vision that is going to help us to turn the page.”

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