Cures for What Ails the Nursing Shortage

By Dr. Kenneth Scott, Jr., DO, CMD

CEO SilverSage Physician Services 

A wise friend and excellent post-acute and long-term care administrator recently suggested on a LinkedIn post that we all know the rate-limiting step to admissions today is not the number of patients needing care but the number of nurses available to provide it. He suggested that it should remind us of that one word that is so very important in retaining staff: culture.

There are many reasons why nurses are leaving the profession. Some of those reasons are part of the natural process of a nurse’s career, such as retirement or a change in situation. Unfortunately, the rate of departure has increased dramatically due to other stressors brought on by the COVID-19 pandemic, heightening issues that already existed in the workforce.

Nursing home corporations often verbalize how important their staff is to the future of the company. At corporate meetings, they will award individual nurses for their accomplishments and applaud the wonderful care patients have received under that nurse’s leadership. Although these are good things to do and should continue, the question remains whether the culture is, by example and action, reinforcing their commitment to their staff or contradicting their verbalized mantra. 

I am a firm believer in actions speaking louder than words. If a dent is going to be made in the nursing shortage, administrators are going to need to address the issues adding to burnout, reduce the penchant to fall back on agency staffing, consider hiring a full-time doctor for their facility, and seek to improve communication, compensation, and culture.

Running on Empty

The US is already on its way to experiencing a shortage of registered nurses through natural causes as Baby Boomers age and the need for health care multiplies. One nursing workforce analysis, for example, found that the total number of RNs decreased by more than 100,000 between 2020 and 2021. That is the most dramatic drop observed in the past four decades.

The overall shortage of nurses is projected to last at least through 2030, with 30 states falling into the significant shortage range and the most intense ramifications forecast in the western region.

More troubling than the cause and effect aging Baby Boomers will have on health care are all the additional reasons nurses are leaving the profession. Nurse.org’s State of Nursing 2022 survey, for example, made the following observations:

• 87% of respondents feel burnt out.
• 84% feel underpaid.
• 83% feel their mental health has suffered.
• 77% feel unsupported at work.
• 61% feel unappreciated.
• 36% feel happy where they are, but changes would need to be made.

Too often, despite the accolades given on certain occasions to hard-working staff members, nurses feel more like a commodity to be traded on the open market than a valued team member who is relied upon to ensure the success of the facility. And even when individual nursing homes or corporations try to ask their nurses how they feel, if their feelings are negative, they often won’t say anything, especially if they need their job. But these survey results speak for themselves.

Post-Acute Nursing Faces Unique Challenges

Through my experience as a medical director, I can definitely empathize with the challenge of burnout most nurses face. In the case of post-acute and long-term care, the “normal” volume of patients that a nurse has to care for far exceeds the number of patients an acute care nurse would normally handle in a given shift. Many nurses are asked to not only keep multiple patients’ medications straight but also give them on time and, when delivering them, meet the other needs or requests of those patients, including noting small changes in condition that could foreshadow a worsening problem. Those problems, if not properly recognized and addressed, could very easily lead to the need for rehospitalization.

I used to be excited when an acute care nurse came to work in the post-acute setting. Although I still appreciate the experience and skills that these nurses bring to long-term care, I now realize that there is a learning curve for acute care nurses in the nursing home setting, just like there was for me, coming from acute care to post-acute care as a physician. I have seen many acute care nurses stumble or even quit because they could not handle the volume of patients assigned to them on day one.

Most nurses that work in the post-acute and long-term care setting are new to the profession, and the nursing home environment provides an excellent opportunity to gain needed bedside experience. As the medical director and full-time doctor for a facility, I feel it a privilege to help expand the education of young nurses and help them understand what the doctor is looking for and needs to make a good decision. When communicated in a positive way—as in talking to a trusted colleague on the quality-of-care team, it is well received.

I have also found that safety concerns can largely be addressed by a full-time physician. During COVID, many discussions spontaneously erupted at nursing stations regarding questions about the virus and vaccination. Although formal meetings could and did occur to educate staff, that one-on-one time with those making difficult decisions and being able to discuss it with a doctor colleague and medical director proved invaluable.

Reward Staff, Reduce Agency Dependence 

Due to the mass exodus, nursing homes, like acute care hospitals, have resorted to agency nursing help to fill their shifts. As a short-term solution, this makes sense. However, in the long run, it is not the best answer. Although corporations fully understand this issue on the accounting side of the ledger, I have often wondered whether they fully understood the implications on the quality-of-care side.

I have found that many agency nurses do have a strong commitment to providing excellent nursing care. However, that extra “something” that applies to regularly employed staff that take pride in the organization and being a part of the family of workers is often missing. A relationship with the patients has not had time to be established and often never gets rooted due to rapid turnover. For the elderly in nursing home care, seeing a familiar and comfortable face becomes very important to quality of life. Knowing the patient personally from day-to-day interactions is what makes CNAs and nurses so special to the well-being of each patient.

For clinicians who show up at nursing homes when they can—organizing those visits around the office, hospital, and other nursing homes they have patients at—having a nurse that is seasoned in post-acute and long-term care is invaluable in understanding the patient’s progression and describing an acute change in condition. When those nurses decide to leave due to burnout or feeling undervalued, the change in morale can be palpable.

Finding a way to fairly compensate nurses—especially during times of crisis such as COVID or soaring inflation—can help to reduce the dependency on agency staffing. It is also demoralizing when more of your staff is agency who are getting paid at a much higher rate than the full-time nurses that your facility has truly relied on. The full-time nurses are even more prone to feel devalued under those circumstances.

Although pay is often not the main factor in departures in the nursing home setting, as inflation has soared, certified nursing assistants have had to make hard decisions regarding their level of pay and whether it is worthwhile to leave their family for routine shifts when they can barely afford the gas to get to work.

Although it is daunting to think about raising wages for your regular staff, it should be considered as part of your solution. The increased costs of staffing could be substantially offset by applying a portion of the money spent on training and retraining staff, as well as soaring recruitment costs, the actual cost of agency work, and the fact that buildings tend to lose even more full-time staff when they are mainly staffed via an agency. And, of course, the facility’s long-term reputation can and has been harmed in many buildings due to the lack of full-time staff and a reliance on rotating agency staffing.

A Full-Time Doctor Can Stabilize Staff

Many of the above-mentioned issues can be alleviated by nursing homes employing their own full-time doctor on staff. Several years ago, I was presenting this concept to a group of community physicians associated with a nursing home in the area. One doctor raised his hand and voiced an objection.

“If I understand what you are wanting,” he stated, “you are suggesting that when I am in this nursing home, if the nurse comes and tells me about one of my patients that isn’t on my list to see that day, I should drop everything on my schedule and go see that patient.”

I remarked that he was correct but wasn’t sure why that seemed like such a novel concept to him.

“Let me tell you why your plan won’t work,” he said.

He then proceeded to say that the nurses wouldn’t like this plan. He described a situation in the past where he was called into a patient’s room. After an examination, he determined the patient was experiencing some mild congestive heart failure. He began to give orders, including placing an IV in the patient’s arm and administering IV Lasix—just as he would have ordered in the hospital. He reported that he could tell that the on-duty nurse looked visibly upset because he had just complicated her life by giving a bunch of new orders that would now put her behind on her medication pass for all the other patients.

However, we doctors who give orders to send patients to nursing homes, insurance companies that want patients out of the hospital to reduce costs, and hospitals that are losing money when elderly patients remain too long in the acute care setting are all placing complicated and very sick patients in the nursing home. Nurses are more than capable of caring for them with the right support and a timely response from the physician.

I explained that the concern expressed on the nurse’s face was most likely because once he gave those orders, he would leave the facility and head to his office or back to the hospital. In a few hours, when the patient was no better and the nurse needed some help, the doctor would be too busy in his office or the hospital to answer, leaving her feeling alone and unable to give the help the patient needed. This, I reminded him, was why nurses liked the hospitalist model in the hospital so well. In a few hours, if the patient was no better, the nurse would call, I would walk onto the floor, and we would go to the bedside and assess the situation together. This could happen several times in a day—at the end of which the patient was stabilized or transferred to a higher level of care.

In my role as a full-time doctor at a post-acute and long-term care facility, being in the facility every day—especially in the trying times facing the health care industry today—and rubbing shoulders with the rest of the health care team not only helps them feel needed and important in their role but also gives them a relief valve under stressful situations. As the complexity of caring for patients increases, the need for immediate access to a physician increases if patients are going to be kept stable and out of the hospital. 

Strive to Improve Nurses’ Workload

Today, most doctors that are responsible for directing the care of patients in the nursing home either provide care in multiple buildings across a geographic area or provide care at a few homes as an adjunct to their main line of work. Although their expertise provides good support for patients and facilities, the full extent of their ability to assist in good outcomes is lost due to their inability to be present when truly needed. When doctors arrive at the building on their schedule, it often increases the stress on the nursing staff. Multiple orders get delivered in a lump sum on the same day.

Overtime increases, as does the stress on the nursing staff trying to assist the doctor on the one day they arrive and log all the paperwork for the numerous orders produced at the same time. With a full-time doctor on staff, the stress on the nursing staff is reduced, and a reduction in overtime can often be seen. When a doctor examines a patient and hones in on the problem, transfers to the hospital are minimized, fewer labs are ordered, and a thorough review of medications results in fewer rather than more medications given. This relieves the workload on the nurse, limits orders to be transcribed, and greatly reduces the extra workload associated with patient transfers—not to mention multiple discharges and admissions caused by sending the same patient back and forth to the hospital multiple times.

Diagnosing all the issues associated with the Great Resignation and coming up with the right antidote to address them won’t be easy. As with the care of the elderly, there are usually multiple comorbidities acting at once. Each facility won’t need the same prescription, but finding the courage to hear the diagnosis and make the necessary changes will be life-sustaining and make life easier for nurses.