The Future of Emergency Care in an Era of Nursing Shortages

Educational Objectives

The goal of this program is to improve emergency department responses to the current nursing shortage. After hearing and assimilating this program, the clinicians will be able to:

1. List the effects of the nursing shortage during the COVID-19 pandemic.
2. Explain causes of the nursing shortage during the pandemic.

Summary

Demographics of nurses: the speaker notes that health care systems took a reactive, rather than a proactive approach to staffing crises during the COVID-19 pandemic; based on data from 2019, the average age of nurses is 48 to 50 yr; this is usually midcareer or midlife, likely, eg, married with children; women make up 90% of the nursing workforce; 60% work in hospitals; others work in clinics, within government, and in nonclinical roles (eg, legal or advisory, hospital leadership); many roles are open to nurses; the entry level of education is a bachelor’s degree in nursing; the median annual salary is ≈$73,000; the hourly salary is $35 (the speaker surmises that some may make $40-$60/hr); they typically work 36 hr/wk; hourly salary is a big driving factor for the recent exodus from the workforce; most advanced practice nurses are nurse practitioners working in ambulatory care

Impact of COVID on nursing staff: in March 2020, the first wave of COVID began; some locations were affected early; hospitals were overwhelmed with COVID cases for 7 wk; suddenly afterward, hospitals were operating at 25% of typical volume; other hospitals did not see an early wave of COVID but were affected later on; at all hospitals, elective procedures and ambulatory clinics were suspended during shutdowns; only place to get care during pandemic was emergency department (ED) and intensive care unit (ICU); as monetary inflow decreased, team members were furloughed and reallocated; furloughs were the first result, setting up the nursing shortage to come; in June and July 2020, when shutdowns eased and social isolation decreased, EDs saw an increased number of patients but were not as overwhelmed with COVID; in the fall, COVID cases began to increase but there was now a nursing shortage because of pandemic layoffs

Alternate employment options: travel nursing began to play a major role in staffing; this was a symptom, not the cause of the problem; initially travel nursing required uprooting, going somewhere distant, working on transient contracts without benefits, but for ≈3 times more money made at the home base; became very attractive; other nurses opted out of medicine, largely out of necessity but also to follow passions for which they never got an opportunity to pursue before; some were forced to become homeschooling teachers and decided to spend more time with family and children if they were financially stable

Early effects of the nursing shortage during the pandemic: from October 2020 through October 2021, workflows started slowing down and inefficiencies became obvious; every process took longer, from carrying out orders to turning over rooms to waiting times; the available nurses, particularly in environments without prescribed caps or ratios of patients to nurses, were asked to do more with less; this made for an unappealing workplace, resulting in nurses looking for other options

Changes in nursing from fall 2021 to January 2022 (the Delta to Omicron wave): EDs experienced gridlock from October 2021 through January 2022; wait times were excessive (eg, waits for beds ≤24 hr) as nursing staff was not available; health care systems were losing nurses at high rate because of the untenable working conditions and opportunities to make more money; health care systems began to entice nurses away from other nearby systems out of necessity; as a result, travel nurses did not need to travel anymore; nurses were able to work close by and make 3 times more money; nurses who came back to their old hospitals on travel contracts made, eg, 3 times as much money as the employed nurses, who might have trained the travelers; travel companies were now operating from a position of strength, offering benefits, eg, 401(k) accounts, to entice nurses to stay and removing the motivation to return to their former job

Factual causes of the nursing shortage: the most important factor was money; health care systems were losing money through loss of elective cases and downtrending volumes; burnout existed before COVID and was exacerbated by COVID, but the speaker does not think it resulted in as many people leaving nursing workspace altogether compared with the number moving to other sites of employment within nursing field; the “great resignation” has been a topic discussed mainly in reference to burnout, but definite numbers are not known; vaccine refusals and mandates did not likely force enough nurses out of health care to contribute to the national shortage

Theories about the nursing shortage: some nurses believe that executives were purposely seeing how inexpensively they could run the hospital; nurses perceived this as greed; however, the current demand for nursing staff is not as great as in October through January; downswings in hospital volume are creating the “leaner” operating budget through market forces; some think hospitals with nursing unions are purposely forcing nurses out or creating an untenable environment to lessen the bargaining power of the unions but this is unsupported

Root cause for the nursing shortage: health care leadership treated ancillary staff badly; failed to show the value of nurses by furloughing them then trying to get them back by offering referral bonuses instead of paying them retention bonuses; these practices severed the trust and loyalty that had been built up in employees over time; without loyalty, and with better money elsewhere, nurses have no reason to stay; top-level functioning suffers; transient employees do not have the opportunity to get to know the individual system at each ED (eg, throughput, charting, logistics), which affects the workflow and the clinician’s ability to effectively take care of patients; the speaker does not believe that nurses will want to return to an employment model with significantly less pay; the health care system is waiting for the bottom to drop out of the market, forcing nurses to return, but this may not happen

Future projections: demand for nursing staff will likely increase; prior to the pandemic, a 30% nursing shortage was predicted by 2030; although job growth in nursing would increase by 12%, there would not be enough nurses to fill the positions; in addition, travel nursing companies have a projected 10% shortage, which means that nurses will continue to have that opportunity; demand will only increase, as nurses are crucial to the workflow (even at times of low volume); in the next 1 to 5 yr, the new normal may become nurses rotating in and out for 10-wk cycles; ED physicians will no longer be familiar with the nursing staff, eg, who is good at difficult intravenous (IV) line insertions, and will no longer have the same rapport with nurses; the workplace culture will suffer for nurses, physicians, and patients

Other pertinent issues: nurses who do stay will be expected to do more with less resources; physicians may have to act as triage nurses and to carry out their own orders; another major issue is safety; system will start using nurses who do not have appropriate skill set, eg, using licensed practical nurses, internal medicine nurses, or ambulatory care nurses; patients will seek care in other arenas, eg, urgent care, telemedicine; COVID has created fear and distrust of the ED; patients will have less access to procedures and surgery

Prospective solutions: hospitals must mutually commit to stop enticing travel nurses away from from one another; this may require statewide legislation, eg, making it illegal to hire travel nurses whose home base licensure is in that state; this will also make it less convenient to be a traveling nurse; hospitals need to make proactive staffing decisions instead of staffing for low volumes and hiring travel nurses to fill in during busy times; use technology or other solutions to offload some nursing tasks, eg, ordering algorithms, administering medicines, delivering supplies; creative solutions are needed to fill the gap; health care systems need to demonstrate that nurses are valued, reward loyalty, provide an excellent work environment, and compensate fairly

Readings

Haddad LM, Annamaraju P, Toney-Butler TJ. Nursing shortage. StatPearls Publishing. 2022 Feb 22; Lopez V, Anderson J, West S, et al. Does the COVID-19 pandemic further impact nursing shortages?. Issues Ment Health Nurs. 2022; 43:293-295; Ludwig-Beymer P, Vottero B, Coates A, et al. Nursing faculty workload: Balancing fiscal responsibility and faculty satisfaction. Nurse Educ. 2022; 47:174-179; Ma E, Kritsimali A, Olby-Clements B, Boyd K, et al. Innovative staffing solutions to nursing shortages in acute mental health inpatient wards. Issues Mental Health Nurs. 2022; 43:103-110; Nursing shortage or exodus?.Am J Nurs. 2022; 122:12-13. doi:10.1097/01.NAJ.0000822928.16774.9a. PMID: 35200172; Pradeep A, Davis D. A solution to nurse shortages. Br J Nurs. 2022; 31:64-64; Yatsu H, Saeki A. Current trends in global nursing: A scoping review. Nurs Open. 2022; 9:1575-1588.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Bright was recorded at the 40th Annual Emergencies in Medicine Conference, held February 27 to March 4, 2022, in Park City, UT, and presented by Emergencies in Medicine. For more information about upcoming CME activities from this Emergencies in Medicine, please visit EmergenciesInMedicines.com. Audio Digest thanks the speakers and Emergencies in Medicine for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

EM391701

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.