How health systems are responding to a critical nursing shortage

How an unprecedented pandemic and lucrative incentives from travel agencies have accelerated a nationwide nursing shortage, according to Denise Mihal, EVP and chief nursing and clinical operations officer. And more importantly, how leaders are paving a path forward in the first of this two-part series from Novant Health.

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Denise Mihal 0:00
We are in and we are facing the worst healthcare crisis of my lifetime and of my career.

Gina DiPietro 0:10
That's Denise Mihal, a nurse of 35 years (38 total in healthcare), now in her role as Novant Health executive vice president and chief nursing and clinical operations officer. Contributing to that healthcare crisis is a nationwide nursing shortage. It's by no means a new problem, but health systems are facing new challenges. And for a few reasons we explore in this two-part series of Industry Insights: A healthcare podcast presented by Novant Health. I'm Gina DiPietro, your host. To understand what makes this nursing shortage a bit different than before, let's consider what led up to this point...

Denise Mihal 0:53
There's always been a nursing shortage. It made me step back and think, "So, why is this different than any other year in my lifetime - in my career lifetime, at least?' There's a lot of reasons. Everything is exacerbated and accelerated by the pandemic. And if you think about it, our lives changed instantly. We were making changes hourly. What PPE were you using? What kind of masks did you have to use? How are you donning and doffing your equipment? So that was happening professionally. Personally, they were keeping their families and their loved ones safe. And then, "This week, we're in school. Next week, we're out of school.' Some days it changed....You know, childcare just became a complete mess and disaster. So it was a very challenging time for health care and nursing, but they kept showing up to work. They cared for our patients and they cared for each other. And I am in awe and amazement of the strength and the commitment that healthcare providers, nursing had to humankind.

Gina DiPietro 1:48
Unlike storms that wash in and retreat, the pandemic has continued its surge. Also surging is the number of healthcare workers being recruited by traveling agencies. Lured by incentives health systems can't compete with. Take, for example, a conversation Denise shared between herself and a new RN.

Denise Mihal 2:09
I was talking to a nurse who started with us as a new grad, went through the residency program and absolutely loves Novant Health. So, she's leaving to travel. And she stopped me to thank me for the residency program and how wonderful it was. And how it's prepared her to go out as a traveler nurse. But what was interesting about that conversation is - one - she does feel very prepared to go out there. But she's getting a $30,000 sign-on bonus. And she's going to be able to pay off her student loans. Then, she said, if I take another assignment after that, I can use that bonus for down payment on a house or a condo at the age of 26 years old. That's what we're up against. And she even said, 'You know, when this is over, I'm going to come back and work for you.' And I'm like, 'Great, we'll be here.' ... Part of me is going, 'Well then don't leave.' But the other part is how could you pass up those opportunities?

Gina DiPietro 2:16
So we're beginning to understand what's new about the nursing shortage. But as Denise explained it, there are three other causes that have always existed. Baby Boomers are aging. And not only are they getting older, healthcare advancements have them living longer. So they need more medical care. There's also an aging workforce. By the year 2030, an estimated 1 million nurses will be at retirement age. And with 4 million total nurses in the country, about 25% new nurses will be needed to fill their shoes. And finally, there's a lack of infrastructure for education. So academic institutions are actually reducing the number of nurses they accept. But why? Simply put, Denise said nursing instructors can get paid more working elsewhere. Less instructors means less nursing students. It's similar to what healthcare systems are up against as travel agencies recruit healthcare workers with incentives hospitals can't compete with.

Denise Mihal 4:00
It is very difficult to compete with the traveling agencies. The sign-on bonuses, the rates that they're paying right now. And it's not just within Novant Health or in North Carolina. It is a nationwide problem. And when I'm in all of these forums with other nursing leaders, they ask 'What are we doing about staffing? What are we doing about the traveling agencies? What can we do about it?' And you know, it does bring up the paradox. W do have nurses that are leaving for these attractive sign-on bonuses right now. They are at a stage in their life or their careers where they can go. And it's not just nurses. We have respiratory therapists leaving, you name it. CRNAs, physician assistants. The traveling agencies are after anybody with a health care degree and credentials behind their name. And it's very hard for us to compete with that. And in fact, like I said, we can't. But what it does cause is that conundrum because we then have our nurses leaving. So in order for us to bridge that gap from when we recruit and orient and hire a new team member, we have to have a traveling nurse. So then our staff nurses are sitting there next to a traveling nurse that they know are making wages that are much higher than theirs. And they're angry. They're angry that those nurses here. They're angry at us as a health system that we're paying those rates. But what is our choice? Because we have to pay those rates in order to fill the gap until we can hire somebody, train them and bring them on board. And the fact is, it's a temporary contract. I can pay that for 12 weeks or 16 weeks. But when you ask what we can all do, we have to partner with our state and national associations, American Nurses Association, Medical Association, as well as the hospital associations. And we are working with them to address the concerns we have around the travel agencies. You know, are there antitrust laws that are being broken? What can we do? Now, obviously, that's not going to stop who's trying to recruit from us today. But again, we want to make sure that there's no laws being broken about what's going on with these travel agencies and what they're offering . You feel, sometimes, that they're pillaging us, right? That they're stealing our nurses. So there's other things that we have to do (or make sure that we are highlighting for our team members), the other benefits to working for health system, right? Obviously, compensation is huge. People want to feel that they're fairly compensated. I don't think that we can compare ourselves to the traveling nurses and their compensation. And I do think that what we're seeing is ... thank God hope has arrived. And hope has arrived to us in the form of a vaccine and a booster. And what we're seeing on a short horizon, I believe, will be pills, treatments for those with COVID to help shorten the duration and the severity of the disease process. So, once COVID is contained and becomes an endemic versus a pandemic, I think the hold of the travel agencies will start releasing. They won't be able to keep up the rates that they're paying. And we will be able to, as nursing systems and healthcare systems, hire more people back. And so I do want to say for the individuals that have left and have talked to me before they left.. They've said, 'I want to come back and work for Novant Health when I'm done with this travel assignment.' You know, it kind of stings to say 'Yes, we're going to welcome you back with open arms.' But the truth of the matter is, 'Yes, we're going to welcome you back with open arms. Obviously, when you come back, you might not get the shift that you want. It's going to not the shift that you left. It'll be the shift that's available.' But we will hire our team members back.

Gina DiPietro 7:37
You'll remember the conversation Denise shared earlier with the nurse who was leaving to travel. She's one of those former team members who have expressed a desire to later return. She's also one of 450 graduates of Novant Health's certified residency program in 2021. It's building a talent pipeline for nurses, and became even more crucial, Denise said, at the onset of the pandemic.

Denise Mihal 8:03
Think about finishing school these last two years ... as your either your junior or senior year in nursing school, and a pandemic hit. So initially, schools stopped sending their students to clinicals, to hospitals, right? So, we have a Nurse Residency Program, just like doctor's who come out of school and they do a residency and they rotate through different areas. We started that in 2018. So thank God, we had the foresight to do that. But we really had to double down on education because we had to surround them from what they missed their last two years of school. You want to talk about developing that pipeline for future and helping our academic programs provide an extended education to these individuals? I would say that's through a residency program. And that's not offered in every facility, nor is it as good as what we have at Novant Health. So I would say, I'm very proud of that honor and badge that we wear for that. But in addition to that, we're working with our government relations team, and with all these agencies on both the local and national level, to clear those barriers of the immigration processes in order to allow overseas health care workers an easier way to come work with us. Now, why would you say that? Well, remember I said, just even pre-pandemic, we had a nursing shortage with 1 million people who are approaching retirement by 2030. We're going to need a lot of nurses. And they're going to have to come from other places, not just what can be produced in our school system. So we're working with three agencies, foreign agencies, to help us place some nurses. And hopefully they'll be able to be here by the end of 2022. And so we're excited by that because it's also going to help us ... if we talk about the Philippines, the Middle East ... it's going to help us diversify our workforce population so that we are representative of the communities that we work in. And we want our patients to come to us, see people that are like them, speak the language that they speak... We have asked for 300 placements. So that's for our whole footprint and the 17 hospitals we have. And they will be permanent placements. Those will not be travelers. So that is another avenue that we're working to solve some of the crisis that we're having. And again, to move away from using travelers and to get some permanent placements within our facilities.

Gina DiPietro 10:15
Do you think there are also opportunities for Novant Health to make itself attractive to traveling nurses? And maybe they'll stay if it's a great environment?

Denise Mihal 10:26
Great question. And in fact, we are recruiting traveling nurses. We have several that have taken full-time positions with us during this pandemic. They saw that it's a great place to work. We have a special sauce at Novant Health. And this is a very special place. When travelers come to us, they recognize this is a different environment than all the other hospitals that they've worked in either full-time or as a traveler and they want to stay. In addition to that, you know, what would make traveling attractive here is we have the CSSO. That's our Central Staffing Scheduling Office and we have nurses that work out of there. We have 300 RNs and 150 CRNAs. It's our float pool, but it's our internal agency. So, there's a higher rate of pay.... And there's a general float pool. With the general float pool, you would float within hospitals within your market. So, that might be three to five hospitals, depending on the market. And the super float pool is you float beyond that. And it's at an even higher tier pay. You could be assigned to a different unit in the facilities. Let's use Winston Salem, North Carolina, as example. You could work out of Forsyth Medical Center or Thomasville or Kernersville. You could have a daily assignment that changes or you could work this week all out of Forsyth. The next week, you could choose, 'I'm going to work at Kernersville.' So gives you that traveling sort of sense. You're hired at a higher rate of pay, you have the benefits of working within Novant... And you also have the camaraderie of you're known as 'Yes, I'm a float nurse, but I work for Novant. I go to where I'm needed.' And I just will always remember I was working at Brunswick Hospital and I was the president there. And I thank God for the CSSO. Because I don't know what was in the water that year, but I had nine nurses pregnant on my maternity unit at the same time. Which meant I had nine nurses going out on maternity leave within days and weeks of each other. Having an internal float pool, I was able to contract with them to say, "Look, I'm going to need people for like three months.' It was helpful that I'm saying, "You're at the beach, and it's in the spring and summertime, right? So, who wants to come to the beach?' But I was able to do that without getting traveler nurses. Instead, I was able to use our own internal pool. So again, helping us attract the travelers, as well as if you want to stay in .... if you're in the ED or ICU at Forsyth because that's where you feel like you've been welcomed and treated like family... and that's where you want to stay and settle ... you can do that, as well.

Gina DiPietro 12:52
How else can leaders engage nurses differently so they don't leave? And what does the future of nursing look like? What new models of care will health systems consider?

Denise Mihal 13:02
I think healthcare for the future is changing. And that's being written as we speak.

Gina DiPietro 13:13
The answers to what that might look like are in part two of this candid conversation with Denise Mihal, Novant Health executive vice president and chief nursing and clinical operations officer. In the meantime, find other episodes of Industry Insights and other podcasts from Novant Health on Apple, Google, Spotify or anywhere you listen to podcasts. I'm Gina DiPietro, and thank you for listening.