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KELLY BILODEAU
Contributor to Health Progress

Health care staffing shortages were brewing well before the COVID-19 pandemic hit. Three years before the pandemic began, concern was already rising about a wave of impending retirements. More than half of all nurses were age 50 and older, and nearly a third were 60 and older, according to the American Hospital Association.¹ COVID dealt a sudden blow that accelerated the crisis.

"COVID was a huge driver for the present shortage, and for a lot of different reasons: the stress that nurses endured, watching immense suffering before the vaccine, lots of deaths, fear for their own health, fear for their families' [health]," says Mary Ellen Glasgow, PhD, dean of the School of Nursing and vice provost for research at Duquesne University in Pittsburgh, Pennsylvania. But the pandemic didn't just affect nurses. Industrywide, as many as one in five health care workers have left their positions since 2020, according to a report by Definitive Healthcare.² "Frankly, a lot of our nurses and techs and doctors decided that they just weren't able to do the job anymore," says Greg Till, executive vice president and chief people officer for Providence, an organization with 120,000 caregivers across five Western states.

Like millions across the U.S. since the beginning of the pandemic, health care workers quit jobs and abandoned long-term careers, joining a mass exodus now referred to by many as "The Great Resignation." Many people retired early or pursued entirely new roles and opportunities. Hospitals were forced to rely heavily on temporary nurses — who commanded compensation as high as $240 an hour — in addition to other contract workers, such as respiratory therapists. This drove up labor costs, which jumped by as much as 19% per patient between 2019 and 2021.³

Today, hospitals are still struggling with historic staffing shortfalls and the recognition that there is no easy answer — or end — in sight.

"The overall labor market seems to be depleted at levels that I have not seen in my lifetime," says Damond Boatwright, president and CEO of Hospital Sisters Health System (HSHS), an organization with locations across Illinois and Wisconsin. Baby boomers are retiring at a record pace, labor force participation is at a record low and birth rates are decreasing, he explains. Based on these factors, it's likely that a plentiful workforce won't become a reality, at least for the early part of this century, he says.

Some specialties and parts of the country may feel shortages more acutely than others. "If current trends hold, 29 states will not be able to fill the demand for nursing talent, coming up almost 100,000 nurses short in the next five years," states a 2021 report by Mercer.⁴ "The largest projected shortages of nursing talent will be in Pennsylvania, North Carolina, Colorado, Illinois and Massachusetts."

Overall, there's a new recognition among many health care leaders that the old staffing model no longer works. To survive, health care organizations are rethinking old ways and changing everything from how they recruit people, to training requirements, compensation packages and even how the typical workday looks for those delivering care.

"What we really need to focus on as an industry is more transformational ways to change the work of health care, so that we can do it with less people," Till says.

GIVE STAFF REASONS TO STAY
The priority for many organizations is to keep the people they have and avoid any more losses. Surveys show that the mass exodus from health care may not be over. Forty-seven percent of U.S. health care workers in one recent survey say that they have an eye on the door and may exit the field by 2025, according to a report by Elsevier Health.⁵

In hopes of enticing people to stay, health care leaders are increasing pay, adding educational incentives and building career ladders to help people achieve upward mobility without leaving the organization. They're also improving job flexibility, allowing virtual and hybrid work options for some positions, and abandoning the traditional 12-hour shift in favor of schedules that give people more ability to balance their work and personal lives.

PROMOTING BALANCE AND CHOICE
"I like to say that flexibility is the new engagement capital," Till says. "Everyone wants more flexibility, including clinicians." To this end, Providence is implementing, four-, six- and eight-hour schedules.

At South Dakota-based Avera Health, the system has created an internal training and staffing organization aimed not only at filling jobs, but improving retention. Avera Education & Staffing Solutions, which launched its internal travel RN program in November 2021, places both temporary workers and traveling nurses. During the pandemic, Avera was leaning heavily on travel positions, something they knew wasn't sustainable long-term, says Kimberly Enebo, vice president of Talent and Rewards at Avera. An internal traveling RN program was not only a less expensive alternative, but it also provided benefits to employees, she says. The program gives staff members a lot of room to move, says Ryan Donovan, vice president of Business Development at Avera Health. "Maybe they're going to school and they can't work full time. We have temp staff options for them so they can work flexible hours," he says. There are work options not only for nurses, but for CNAs and LPNs as well. And those who are interested can take a traveling nurse position. "Now they can do all of that while staying an Avera employee," Donovan says.

Other organizations are also providing more flexibility through virtual and hybrid work options. Providence, for example, is using virtual nursing to help free up nurses at the bedside, by handling tasks such as going over discharge instructions with patients, reviewing medications or helping to fill out paperwork or answer questions. "Where we've been able to pilot [the program], it's extended the careers of some nurses who can't spend 12 hours on the floor," notes Till.

Organizations also encourage older nurses to stay engaged in the workforce by hiring them for advisory positions to support more junior nursing staff on busy hospital units, says Glasgow. Turnover rates for entry-level nurses can be high in some organizations. Many nurses now entering the workforce lack some clinical experience due to changes made to training programs during COVID. "They're coming here with less clinical experience in an environment where the acuity is through the roof," Glasgow explains. Without the right support, many are getting overwhelmed and leaving within the first year. Investing in nurse advisers can help solve both the retirement and the turnover problem. "We have to be really creative in how we are utilizing the brain trust of nursing," she says.

BUILDING SKILLS, INSPIRING LOYALTY
Organizations are also expanding opportunities for career growth in hopes of keeping staff members happy. "I want people — when we have them in our organization — to feel like they can reach their God-given true and full potential," Boatwright says. "And I want them to feel like they've got a number of different career opportunities just here in the organization. You can move up and move around, but you don't have to move out." Like other organizations, HSHS offers career levels and clinical ladder programs. "We also offer learning opportunities to emerging and current leaders," he says. These are in addition to scholarships, tuition discounts, tuition reimbursement and student loan repayment programs, Boatwright says.

In addition to job flexibility and support, organizations also recognize the need to address the emotional and physical health needs of staff members. The pandemic took a harsh toll, and many people are now struggling with symptoms such as fatigue, depression and anxiety, Boatwright says. HSHS is using a 24-hour-a-day, seven-day-a-week employee assistance program that provides confidential counseling assessments and referral services for staff members at no charge. Providence has a similar program. "We implemented a program last year where almost every one of our caregivers has access to mental health resources immediately. We pay for them to meet with a counselor if they want, up to 26 times a year," Till says. The organization has also trained internal staff members to recognize signs of distress in their coworkers. "We've gotten really good at helping folks through some of the most difficult mental challenges that they might be having as well," Till says. Ultimately, health care organizations can offer the right salary and job description, but if workers don't feel supported and valued, it's not uncommon for them to explore other opportunities for a better fit or in hopes of a more fulfilling career.⁶

GET CREATIVE WHEN SEARCHING FOR CANDIDATES
In addition to a focus on staff retention, organizations are refining strategies to attract new workers to the profession by revamping job benefits, streamlining education and training requirements, and dipping their buckets into historically overlooked talent pools.

Instead of coming up short after mining the usual sources for workers, recruiters are turning to new areas to find potential candidates. To tap into these markets, leaders need to engage with the community and serve on local boards, suggests Heather Brenden, a senior director of human resources at Intermountain Health's Montana and western Colorado regions. Intermountain is headquartered in Salt Lake City. They've also got to forge ties not only with colleges and universities, but high schools. This enables health care organizations to introduce themselves to younger people and encourage them to consider health care as an option, she says.

Health care groups also are actively recruiting from other industries, and enlisting staff members to find recruits. "We've invested in a colleague referral program," Boatwright says. "I pay them to recruit." Staff members are paid bonuses when their referral is hired. The bonus amount varies based on the position filled. "In 2022, 21% of overall hires came from our Refer a Friend Colleague Referral Program," says Boatwright. "Staff members have become some of the best recruiters that we have."

ILLUMINATE A PATH TO SUCCESS
While offering competitive salaries has become a necessity, it's a recruitment strategy that has its limits. "The cost of that is not sustainable given that revenues are falling short to make up for it," Boatwright says. With this in mind, organizations are using novel incentives to help draw in potential candidates. "It used to be just a sign-on bonus. Right now, we're trying to be more creative," Brenden says. "What works for you? What do you need? Would it be a housing stipend or would it be something different?"

Many organizations are offering tuition assistance and other types of compensation for education. At Intermountain, they've made the program even more flexible. "[Our] program can also be shared with qualified family members. So, if a caregiver doesn't use their educational support benefit, they can share it with a family member," Brenden says.

Another incentive that distinguishes one organization from another is the potential they offer for career advancement. For people coming into entry-level positions, charting a defined career pathway that will allow them to advance and build their skills quickly helps to make these jobs more appealing than other entry-level jobs with comparable pay, Brenden says. "When people see a pathway to where they can go from what they perceive as an entry-level position up to a position that is not entry level, they realize they could build a career. Creating those pathways and giving them a solid plan to get there is huge," Brenden says. "You see the light go on, and then they're not just plugging in and coming in for that shift. They're coming in to help build themselves."

RETHINKING TRAINING STRATEGIES
To get people into the workforce as quickly as possible, schools and hospitals are also collaborating to streamline education and training programs, focusing on prioritizing the most crucial elements. They're also looking to remove some of the unnecessary barriers that may make it harder for certain students, particularly those from less affluent backgrounds, to enroll.

"We are test optional here at Malloy. We don't require college aptitude tests, such as the SAT or ACT, for admission to the nursing program," says Marcia Gardner, dean of the Barbara H. Hagan School of Nursing & Health Sciences at Molloy University in Rockville Centre, New York. This eliminates one barrier for students who may not be able to afford test preparation courses due to cost.

Some health care organizations are considering moving away from hardline degree and tenure requirements. "Something that we're really looking at is redesigning all of our job descriptions, capabilities and requirements in order to lower the barriers to entry to health care professions," Till says.

The vision is to create a skills and capability-based model that allows people to build quickly and advance from a solid foundation. Instead of going back to school for four or six years to get a degree, people would instead get more tailored training in the skills they need to effectively do the job, Till says. This type of skills-based approach will make it easier to attract new candidates from more underprivileged settings and access talent starting at the high school level.

Nursing programs are willing to adapt to the needs of an ever-changing industry, Gardner says. "We're trying to have a new vision as to how to make sure that nurses are educated for the needs of now, and also the needs of an unknown future," she says. This may mean shifting to a competency and outcomes focus, instead of a process focus.

USE TECHNOLOGY WISELY
However, even if retention and recruitment strategies are successful, health care organizations may still come up short of the staff numbers they need. "No matter how much we spend, it's not going to solve the macrolevel demographic issues that we have," Till says. So, organizations are also looking to technology to help increase efficiency. Providence is using data to predict patient flow to optimize scheduling and give nurses more flexibility, Till notes. They're also aiming to digitize more processes to cut the administrative burden on staff members.

"We're doing things like predictive hiring, opening roles before they're technically available, to limit vacancy time," he says. Technology can spot patterns, identifying where demand might surge so that the organization can be prepared. "All those things are aimed at really helping us today with our workforce challenges," Till says.

Technology is also helping to speed recruitment, Boatwright says. Some HSHS interviews, introductions and career fairs are offered virtually to allow people to drop in quickly without taking a full day off from work. It's crucial to streamline the hiring process and to make offers quickly to stay ahead of the competition. At Avera, they gave hiring power directly to nursing leaders to accelerate the process. "The first person who's out there with that applicant to get them interviewed and an offer made is probably the winner, so we needed to be able to speed that up," says Enebo.

LOOKING AHEAD
It's been more than three years since the start of the pandemic, and as organizations look to the future, there is hope that health care operations are starting to stabilize.

"In 2023, there's probably not going to be a whole lot of wind at our back in health care," Till says. "But we'll have less wind in our face." And there's hope that the changes being made now will make a difference going forward.

As Till explains, "What I'm most excited about is, I think, that while the supply-and-demand challenges are not going to get easier on their own, that many of our solutions are going to help curb the challenges, and they're also going to bring the joy back in practice for our clinicians."

KELLY BILODEAU is a freelance writer who specializes in health care and the pharmaceutical industry. She is the former executive editor of Harvard Women's Health Watch. Her work has also appeared in The Washington Post, Boston magazine and numerous health care publications.

NOTES

1. Stacey Hughes to Frank Pallone, Cathy McMorris Rodgers, Diana DeGette, and H. Morgan Griffith, American Hospital Association, Washington, D.C., March 1, 2022, https://www.aha.org/lettercomment/2022-03-01-aha-provides-information-congress-re-challenges-facing-americas-health.
2. Ethan Popowitz, "Addressing the Healthcare Staffing Shortage," Definitive Healthcare, October 2022, https://www.definitivehc.com/sites/default/files/resources/pdfs/Addressing-the-healthcare-staffing-shortage.pdf.
3. "National Hospital Flash Report," Kaufman Hall, January 2022, https://www.kaufmanhall.com/sites/default/files/2022-01/National-Hospital-Flash-Report_Jan2022.pdf.
4. Tanner Bateman et al., "U.S. Healthcare Labor Market," Mercer, 2021, https://www.mercer.us/content/dam/mercer/assets/content-images/north-america/united-states/us-healthcare-news/us-2021-healthcare-labor-market-whitepaper.pdf.
5. "Clinician of the Future: Report 2022," Elsevier Health, March 2022, https://www.elsevier.com/__data/assets/pdf_file/0004/1242490/Clinician-of-the-future-report-online.pdf.
6. Victor Lipman, "66% of Employees Would Quit If They Feel Unappreciated," Forbes, April 15, 2017, https://www.forbes.com/sites/victorlipman/2017/04/15/66-of-employees-would-quit-if-they-feel-unappreciated/?sh=604551706897.