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    Hospitals innovate amid dire nursing shortages

    COVID-19’s latest surge exacerbates long-standing forces driving nursing shortfalls, prompting an all-hands-on-deck scramble to maintain patient care.

    A nurse in hospital scrubs looks up from her checklist

    At Parkland Health & Hospital System in Dallas, doctors have been stepping up for duties normally done by nurses and medical assistants, such as turning and bathing patients.

    At UAMS Medical Center at the University of Arkansas for Medical Sciences (UAMS) in Little Rock, administrators have been recruiting new nurses with signing bonuses of up to $25,000.

    And at UAB Medicine in Birmingham, Alabama, nursing school faculty have been leading teams of students in turning critically ill COVID-19 patients from their backs onto their stomachs (knowns as proning) so they can breathe better.

    “I’ve never seen such teamwork. It’s been a mind-blowing experience,” says Summer Powers, DNP, CRNP, an assistant professor at UAB School of Nursing who helped to organize the faculty/student teams.

    Also never seen before are the staffing shortages that are plaguing hospitals in the latest COVID-19 hot spots, forcing them to offer eye-popping employment bonuses and draft everyone — from students to administrators to physicians — to fill in the gaps as best they can. While shortages abound across front-line jobs, nowhere is the need greater than in nursing, as hospitals hit by the current surge report unprecedented vacancies in nursing slots: 470 out of 3,800 positions at Parkland; 240 out of 1,400 at UAMS; and 760 out of 4,000 at UAB.

    “It’s a dire situation,” explains LouAnn Woodward, MD, vice chancellor at the University of Mississippi Medical Center (UMMC).

    The situation keeps growing more dire throughout the pandemic, which exacerbated conditions — including widespread staff burnout and an aging workforce — behind a looming nationwide nursing shortage. The current surge of the delta variant has found front-line caregivers particularly vulnerable, both physically and emotionally, because they had been moving ahead in confidence that the worst of COVID-19 was behind them.

    “Everybody on the front lines just feels like this tsunami has come and hit us,” Woodward says.

    Burnout fuels exodus

    Health field leaders have been warning for years that hospitals face a nursing shortage. One widely cited study projects a shortfall of 510,394 registered nurses by 2030. The main reasons, according to such groups as the American Nurses Association, are waves of baby boomer nurses entering retirement age, an aging population that will require more medical care (and more doctors and nurses), faculty shortages that limit the capacity of nursing schools to accept more students, and more nurses moving away from direct patient care or leaving the health field altogether because of stress.

    COVID-19 has intensified some of those conditions. The first surges last year compelled many nurses and other health care workers to leave their jobs, but the vast majority battled through the exhaustion, despair, and fear out of a sense of duty and with faith that medical researchers would find ways to combat the disease. They just had to hang on until then.

    “When we were able to jump in with vaccinations in January [2021], there was a sense of great hope,” recalls Tricia Thomas, PhD, RN, associate dean for faculty affairs at Wayne State University College of Nursing in Detroit.

    In many places, however, that hope has been extinguished by the current COVID-19 surges. “We were already fatigued and weakened and frustrated — and we got slammed again,” Woodward says.

    This time, the exhaustion of caring for critically ill patients is paired with frustration over the disease’s repeated resurgence. As the delta variant hits some areas harder than previous surges did, and as the nation stands divided about stemming the pandemic through vaccinations and masks, many health care workers see no end in sight.

    “There’s a feeling of betrayal by the society,” explains Patricia Pittman, PhD, director of the Fitzhugh Mullan Institute for Health Workforce Equity at George Washington University in Washington, D.C. “There’s incredible frustration that this was avoidable.”

    More and more front-line hospital nurses have decided to leave for less stress or more pay, and they’re finding lots of options:

    Retire: “We have seen nurses who, a year ago, were in a mind frame of, ‘I may retire in the next few years.’ When the pandemic hit, they decided this was the time,” Woodward says.

    Quit for a while: Some nurses have realized that they can afford to leave the workforce and spend more time at home with their families while considering their professional futures in health care or elsewhere. “They learned they can do that and not have to deal with the emotional and physical toll of the ongoing pandemic stress,” explains Justin Precourt, RN, MSN, chief nursing officer at UMass Memorial Medical Center in Worchester, Massachusetts.  

    Take less stressful jobs: Thomas notes that credentialed nurses have more opportunities than they did years ago to work away from front-line acute hospital care, such as attending to outpatients in clinics, assessing claims for insurance companies, teaching, and going into management. “There’s a much greater nursing world out there beyond acute care,” she observes.

    Earn more money: Nurses are increasingly leaving direct hospital employment for the higher pay provided by so-called traveling nurse companies, which hire nurses as contractors to work at various hospitals for fixed periods. While some nurses took advantage of this opportunity early in the pandemic, hospital leaders say the surges of 2021 have accelerated the trend, as rising demand for nurses leads traveling nurse companies to offer them more money. Some companies pay up to $150 an hour with signing bonuses that reach $20,000. “There’s no way they [hospitals] can compete with the travel agencies,” Pittman says.

    CEOs are concerned, however, about agencies recruiting nurses from their hospitals and then hiring the nurses back to those hospitals at two to four times their previous rates of pay, explains Janis Orlowski, chief health care officer at the AAMC (Association of American Medical Colleges). She says that the AAMC will raise the issue with federal regulatory officials.

    Impact on staff and patients

    The vacancies leave the remaining staff straining to deliver high-quality care — and not just for COVID-19 patients. Unlike during previous surges, many hospitals have not canceled elective surgeries this time around — and some are treating more patients than ever for non-COVID-19-related illnesses that had been neglected. As a result, hospitals in hot spots are triaging some procedures, such as surgeries for conditions that are not immediately life-threatening. UMMC turned to a nonprofit to create and staff a field hospital in a parking garage. Parkland Health & Hospital System transferred some patients with planned elective C-sections to other hospitals.

    Meanwhile, front-line clinicians like doctors, nurses, and medical technicians are putting in extra hours, caring for more patients, and taking on extra tasks, while other staff get drafted to provide nonclinical support. Just about everyone who chips in has to learn new skills and procedures.

    “I don’t fully understand what a pharmacist does any more than a physician fully understands what a nurse does,” Thomas notes. “Part of what makes all of us effective in the work that we do is that we have repeated experience doing it.”

    Adding to the workload is that some hospitals are suffering significant vacancies in other jobs as well, including respiratory therapy, medical tech, environmental services, and food services. As with nurses, many of those workers have found work in less-stressful health care settings or outside of health care altogether.

    “There's a sense of, why work in a high-stress environment where there's a risk of getting infected [in a hospital], when they can find work elsewhere,” often with “better working conditions and shorter hours,” says Steppe Mette, MD, CEO for UAMS Medical Center.

    Mette notes that 100 of the 396 patient care technician slots at UAMS Medical Center are vacant. Those vacancies put even more strain on nurses because, in many cases, “they’re the only ones that can make up that difference” by providing care, he observes.

    These labor market dynamics make it more difficult than ever to fill the empty slots.

    “We’ve always had openings, but we had a strong candidate pool to hire from,” Precourt says about the nursing staff. “What has really shifted is that the candidate pool has dried up while demand has increased exponentially.”


    Hospitals are employing several strategies to fill the gaps in nursing for the short term.

    Tapping staff doing nonclinical work: Employees whose jobs do not involve clinical care are stepping in to serve patients or take on other tasks to ease the burden on clinical staff.

    At UMass Memorial Health, administrators with clinical licenses have been pulled in to provide patient services in line with their skills, Precourt explains. Parkland and UAB established sign-up systems for staff to see what tasks are available, enter their skills to match certain needs, and offer time slots to work. The duties range from delivering meals and transporting patients through the hospital to providing bedside care and guiding patients through discharge. The paid assignments are usually carried out beyond someone’s regular work hours.

    Among those signing up was Powers, the UAB teacher who brought students along for the assignment. 

    Tapping educators and students: Powers, a nurse practitioner, accepted a request from the nursing school for faculty to help fill nursing gaps at the hospital. “Some of us haven’t worked at the bedside in years as nurses. It’s scary,” Power says. “But if we teach our students to do this [respond to emergency needs], we should be going to do it ourselves.”

    She and her colleagues initiated a system whereby one nursing school faculty member leads a team of four students who volunteer in shifts. One of their main tasks has been helping nurses to turn ventilated patients into the prone position — a strategy that has proven lifesaving in some cases. But the process is labor-intensive, because the patients are medically fragile and connected to numerous devices. It typically takes nine people 45 minutes to safely turn one ICU patient, Powers explains.

    In hot spots around the country, medical, nursing, and pharmacy students are in hospitals doing everything from helping to transport patients and ferrying lab specimens to delivering meal trays and emptying trash cans.

    Jacob Garrett has delivered bed linens, among other tasks, at UMMC. “The main thing I feel while volunteering is a strong sense of community and relief to no longer simply be a bystander in the suffering of your peers and the community,” Garrett says. “I found I could easily help make life a little easier for our staff and help our patients.”

    Recruiting: Many hospitals are offering signing bonuses for nurses to work in specific high-need areas. UAMS, for example, offers a $25,000 bonus for experienced acute care nurses (paid over three years). In addition to signing bonuses, UMass Memorial Health offers its current nurses up to $5,000 for referring nurses who take critical jobs there and stay for certain lengths of time, Precourt explains.

    In Texas, the Department of State Health Services is recruiting 5,500 "medical surge staff" from other states to temporarily work in Texas hospitals that are overburdened by COVID-19.

    Woodward sees the irony in hospitals filling vacancies by increasing their recruitment of nurses from other hospitals and using traveling nurse companies. “We’re contributing to the problem,” she notes, but she sees no choice for now. “It’s robbing Peter to pay Paul — and Peter’s getting mad.”

    Retaining: Some hospitals are raising salaries and offering bonuses to keep their existing nursing staff. UAMS recently announced $10,000 retention bonuses for nurses who have been at the organization for at least three years and work in certain high-need units. Parkland offers some of its nurses temporary contracts that pay close to what they might receive through a traveling nurse company; when the contracts expire, they can resume their regular employment.

    “The benefit is they can stay in their home hospital, the hospital is able to retain them, and we will float them to the area of the hospital in greatest need,” says Roberto de la Cruz, MD, Parkland’s executive vice president and chief clinical officer.

    Taken together, the efforts are working — so far.

    “I don't know how long we can continue,” says Mette at UAMS Medical Center. “It’s like running a marathon, straight out. But at some point, you have to get time off. We're hoping for a break in the wave.”