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Walk into any health care system board room in North Texas, and the major topic of conversation is likely the same: How do hospitals break the ongoing cycle of staffing shortages before the next COVID crisis?
The pandemic exacerbated staffing woes for Dallas-Fort Worth hospitals, but it certainly didn’t create them. And now, during a relative lull in COVID hospitalizations, health care centers are racing to catch up to pre-pandemic staffing levels, which were already moving in an alarming direction.
AMN Healthcare, one of the largest temporary health care staffing companies in the U.S., currently has more than 2,000 outstanding requests for clinical positions it can’t fill in North Texas. Group president of nursing and allied solutions Landry Seedig said there just aren’t enough candidates to fill those vacancies.
“We’re just in a major nursing shortage and clinician shortage overall. We’d actually define it as crisis levels across the United States,” Seedig said. Hospital leaders “have ideas of how to move forward, it’s just that a lot of those ideas are more long-term. They need something that’s more immediate.”
Solutions to the root causes of hospital staffing shortages – an aging workforce, widespread burnout and nurse training limitations, among others – require systemic changes, such as a broader pipeline for health care students and better wage and time benefits. But they’ll take months or years to implement. Hospitals are desperate for short-term solutions before another potential onslaught of COVID-19 patients flood emergency departments and intensive care units.
Hospitals are already upping the anti in an attempt to recruit and retain highly-needed staff. Parkland Health, Dallas County’s public hospital, increased spots in its introductory nursing programs and created an internal travel system for nurses looking for more flexibility in their assignments.
The push is working, to some extent. Before COVID, the hospital had around 1,000 open positions, a number that peaked around 2,200 during the pandemic. Vacancies have decreased to 1,800, said Stacy Dorsey, Parkland vice president and chief workforce officer.
“Right now we’re moving in the right direction,” she said.
But, with The Texas Workforce Commission expecting the state to have a deficit of more than 57,000 registered nurses by 2032, hospitals still have a long way to go.
Pre-COVID problems
Analysts sounded the alarm over health care staffing shortages long before the coronavirus spread across the globe.
The U.S. has repeatedly faced nursing shortages, as detailed by a University of Pennsylvania School of Nursing history on the subject. One of the first such shortages began in the 1930s and continued into the 1960s, even as health leaders increased the number of students admitted to nursing schools, shortened the length of nursing education and increased hiring in positions designed to assist nurses.
Those strategies successfully added more nurses to the workforce, but nurse shortages kept resurging. One study published in the Journal of Nursing Administration in 2002 predicted a nursing shortage that would extend into 2020, citing worker burn-out and an increasing average age of nurses in the workforce. That prediction has proven true.
Nurses aged 65 or older made up 19% of the nursing workforce in 2020, up more than 4 percentage points since 2017, according to the 2020 National Nursing Workforce Survey. That age group comprised the largest age category in the survey.
And, with workloads increasing as staff numbers decrease, more and more nurses are reporting burnout. Even before the pandemic, more than 70% of nurses said they were experiencing burnout in a November Hospital IQ survey of more than 200 hospital registered nurses. Those feelings of exhaustion have only increased under the pressure of COVID-19.
Burnout from working in an understaffed unit contributed to Dawn Webb’s decision to leave her job at a mental health clinic in 2019 after seven years in the profession. Even in her current role as director of practice at the Texas Nurses Association, which represents more than 16,000 members across the state, she constantly witnesses the toll of untenable workloads.
“We go into nursing to care for people, to help them heal and to help them recover,” Webb said. “Yet we’re put in these positions where we’re spread so thin that we’re not able to do what we really signed up for.”
After more than two years of COVID-19 adding even more stress to an already overworked group of professionals, health care experts are more vocal than ever that something needs to change.
An education bottleneck
Despite the shortage in registered nurses, University of Texas Arlington College of Nursing and Health Innovation clinical assistant professor Cynthia Koomey said there’s no shortage of students interested in and qualified for nursing school.
UT Arlington’s nursing program graduates between 800 and 900 students per year, and they still have to turn away qualified applicants.
“We have so many qualified applicants that we just can’t accept because of limited clinical facilities for them to do their clinical rotations at,” Koomey said.
In their final semester of the two year program, UT Arlington nursing students complete more than 100 hours of training at a specific health care facility working one-on-one with an experienced nurse.
UT Arlington partners with major health organizations across North Texas for these clinical rotations, placing students with Baylor Scott & White Health, Children’s Medical Center Dallas and Medical City Healthcare. The school has to compete with other nursing programs for clinical spots because there aren’t enough experienced nurses to take on students.
“While they’re doing clinicals, the nursing staff and the clinical faculty are having to teach the nursing students, and it’s a lot of work. It’s hard on the staff,” Koomey said.
Nursing schools and hospitals, both of which want to increase the number of students going through nursing programs, are stuck in a never-ending loop: Nurses in understaffed units can’t take on as many nursing students because of how much work they have, which limits the number of students nursing schools can accept. Fewer nursing school graduates means fewer new nurses to recruit to understaffed units.
To combat this cycle, the Texas Workforce Commission announced in February that $15 million in funding will be allocated to a statewide apprenticeship initiative with the goal of expanding opportunities for people interested in nursing and other health care professions.
The initiative will be “built on the foundations of” providing paid registered nursing clinicals, hosting workshops on health care career topics and developing pathways for students who have completed registered apprenticeship programs to earn college credit.
Koomey said UT Arlington is looking for creative ways to increase clinical opportunities. In the last year, for example, students have gotten clinical hours for volunteering at COVID vaccination drives. They’re also working to get students into clinical settings even earlier in their studies.
Recruitment and retention
Hospitals now have to make the case to nurses that their facility offers more than other health care organizations, including more lucrative positions with travel nurse agencies. Companies are upping starting salaries, creating more entry-level programs and making job assignments more flexible.
Parkland Health is expanding its slots for nurse residencies, which provide new nursing graduates with an on-ramp to full-time employment.
“We take brand new nurses, train them in a subspecialized area and then give them the Parkland experience,” said Parkland Health Chief Medical Officer Dr. Joseph Chang. “We hope that means the more we train, the more we impress, so then hopefully they’ll stay after training.”
While a sense of comfort could be key to retaining new graduates, flexibility might be the answer to keeping seasoned nurses on staff. Temporary positions through staffing agencies have gained popularity in recent years, especially during the pandemic, because of better pay and the opportunity to experience new work settings.
“A lot of times you’ll see that these temporary clinicians, they’re looking for more flexibility,” AMN Healthcare’s Seedig said. “It’s great that they can go and work a 13 week assignment somewhere in the United States and then they can actually take time off after that.”
Parkland can’t compete with the allure of national travel, but it has started offering staff the opportunity to move within the health system. Employees can apply to the hospital’s internal travel program to hop between different teams and units. So far, the program has proven quite popular, Parkland’s Dorsey said.
Internal travel participants get paid more than traditionally-staffed nurses, although they give up their full-time benefits. Starting salaries for new nurses are $30 per hour, and internal traveler nurses make at least twice that.
“There’s advantages and disadvantages for both [pathways],” Dorsey said. “And we have a limited amount of those traveler spots open. Obviously, we need the majority of our folks to be in full-time jobs on the units taking care of patients each day.”
The internal traveler program may not last forever, at least in its current iteration, she said. But the hospital has received the message from its staff that they want more options in what type of work they do and what kind of schedule they have.
Some of the other large North Texas health care players declined to answer questions about their hiring statistics. Parkland said it tracks with its peers across Dallas in vacancy rates, pay and efforts to recruit nurse residencies.
Regardless of which solution health care organizations pursue to better staff their units, Webb said something needs to change – and fast – for the wellbeing of both patients and nurses.
“For nurses, if you can’t do a good job anymore because you’re spread so thin, why would you want to stay?” she asked. “Morally it just does not feel good for nurses anymore.”