NOTE: This message was emailed to all Ballad Health team members from Alan Levine on Monday, June 7, 2021.
Dear Colleagues:
Over the past several months, as the intensity of the COVID-19 crisis has begun to gradually recede, we are now seeing in our hospitals what we had feared would happen — an increase of burnout among our team members who have been at the front lines of the pandemic even as they have also been caring for the ongoing non-COVID medical needs of our community. This burnout has caused an increase in the number of nurses and frontline caregivers leaving the intense inpatient environment. Combined with a flood of high-acuity “pent-up” volume, the shortage is placing even more stress on our remaining med-surge nursing staff and other clinical team members. As you know, this stress results in shortages of staff, which impact our ability to accommodate the volume of patients on our med-surg floors, which then has the cascade effect of impacting our emergency departments. Everyone then feels the effect.
Let me be clear that this issue is not unique to Ballad Health. It is happening all over the nation. And while the focus of this message is primarily nursing, the national crisis is not just a nursing one. The pandemic and these external factors are affecting health care professionals throughout the spectrum of care.
Specific to nursing, I want to share some data to give you some perspective on what we are seeing. Considering this data predates COVID-19, I think we can safely presume the situation is now worse than it was pre-COVID:
- The Bureau of Labor Statistics projects 175,900 openings for registered nurses each year through 2029.
- Nursing school enrollment is not growing fast enough to meet the projected demand for registered nursing services, despite the American Association of Critical Care Nurses (AACN) projecting a 5.1% enrollment increase in nursing entry-level baccalaureate programs.
- According to the American Association of Critical-Care Nurses, United States nursing schools turned away more than 80,000 qualified applicants from baccalaureate and graduate nursing programs in 2019 due to insufficient numbers of faculty, clinical sites, classroom space and clinical preceptors.
- A 2018 survey by the Health Resources and Services Administration found the average age for a registered nurse is 50 years old, which suggests there will be a wave of retirements in the coming decade. One publication projected more than 1 million nurses will leave the workforce by 2030.
- At the same time the nursing shortage is growing, the U.S. Census Bureau reported that the number of U.S. residents 65 years and older is projected to be 82 million by 2030. Regions with a high elderly population (like ours) will clearly feel the biggest burden from this in terms of disproportionate demand for nursing care.
- Several publications, all of which pre-date the pandemic, found that more than 75% of nurses surveyed believe the nursing shortage presents a major problem for the quality of their work life, the quality of patient care and the amount of time nurses can spend with patients. The acuity of patients in hospitals is as high as it has ever been. As the population continues to age with more comorbidities, this problem will become exacerbated.
- Looking ahead, almost all surveyed nurses see the shortage as a future catalyst for increasing stress on nurses (98%), lowering patient care quality (93%) and causing nurses to leave the profession (93%). One national study found 13% of newly licensed registered nurses had changed principal jobs after one year, and 37% reported they felt ready to change jobs. Other studies found the number of nurses leaving the workforce each year has grown from 40,000 in 2010 to nearly 80,000 by 2020.
As I said, all this data describes the problem BEFORE the pandemic. Despite the national statistics prior to the pandemic, at that time Ballad Health’s nursing turnover rate was actually lower than the national average. The progress made since the creation of Ballad Health was significant, with benefitted nursing turnover decreasing by almost 40 percent.
During the pandemic, specifically in July 2020, we began to see an increase in turnover concurrent with an increase in COVID-19 cases and intensity/acuity in the hospitals. This turnover rate spiked until October, when we were in the throes of the surge and our deferral of elective procedures.
Throughout our experience with the pandemic, we have worked hard to listen to the voices of our clinical teams so that we could provide whatever support we could. We have brought significant temporary, or contract, labor to our hospitals to help manage the workload. We guaranteed nursing and respiratory care hours, and we required certain team members to provide at the elbow support wherever possible. And, as you know, in October, Ballad Health took aggressive steps to mitigate turnover, including investing in wages for nursing and other positions with shortages. The 10-year cost of the investments we have made in nursing and the other key areas, including lab, are already totaling more than $430 million. This is staggering in terms of the incremental investment, but it was a necessary commitment for us to make.
To a large extent, these investments have helped. Our bedside nursing turnover is stabilizing; however, the stabilization level still remains too high. For example, from July through April, Ballad Health hired 386 new nurses, but during that same time, more than 430 decided to leave the hospital environment.
From listening to our nurses, we are hearing clearly that, in addition to the steps we have already taken, they support two additional things we all agree need to be done:
(1) Hire more nurses as quickly as possible so we can get ahead of the turnover and, (2) provide more support to reduce the stress levels of our current nurses.
I want to share some of the steps we are taking to invest in additional resources that we believe, based on direct feedback from frontline nurses, will have a positive impact on the quality of the work experience for our frontline nursing team, including, among other things:
- The addition of dozens of nurse management and nurse leader positions throughout the system designed to reduce the ratio of nurses to leaders. The evidence shows that a lower ratio helps provide more meaningful mentorship and support for bedside nursing and ensures more resources for ongoing competency evaluation and coaching.
- The addition of clinical educators for the purpose of assisting new graduate nurses in their transition to practice at our tertiary hospitals – JCMC, BRMC and HVMC, in the ICU, Emergency Department, Cardiac, PCU and Med/Surg. The additional educators will be able to provide at-the-elbow support for recently graduated nurses, helping to advance their skills and to provide real-time support for these valuable nurses.
- The addition of clinical educators for the purpose of expanding our Certified Nursing Assistant training programs. We plan to lean heavily into recruitment of CNAs at the high school level to provide a pathway to a nursing career. The addition of clinical educators will help us expand this program as we also seek to expand this pathway in partnership with academic institutions.
- We will be implementing a Nursing Ambassador program – engaging our team members who trained at schools outside our region to assist in recruitment from their respective programs. This program will include incentive payments to our nurses for successful recruitment. This idea originated from one of our own nurses, and we are excited about it.
- Expanding the Ballad Health scholarship program to include LPNs.
- We are hiring an additional academic liaison/recruiter to enhance our in-house recruitment team.
- The addition of clerical support for nursing leadership at JCMC and HVMC to assist our nurse managers in our higher acuity/busiest units. Again, the purpose is to provide more meaningful time for the nursing leadership to focus on supporting the front-line caregiver team.
- The addition of 100 new dedicated unit clerks/unlicensed nursing assistants to provide additional support for our nurses on acute care units and in the emergency departments.
- Capital expenditures to add Vocera to HVMC in all patient care areas and in the emergency department. This will provide a much-needed tool which has never been available at Holston Valley.
- Capital expenditures to add 10 new bladder scanners at HVMC and BRMC – this will ensure every unit has one more readily available.
- Systemwide replacement of all MAK carts and wireless scanning devices. We are embarking upon a major capital commitment of $10 million on a two-year plan to replace these items throughout the system. This plan will begin implementation this summer.
These steps have all been approved, and we expect implementation will begin immediately, but also will take some time to ramp up. Hopefully, the effect will be felt relatively soon. There are additional steps we are taking, which we are not yet prepared to announce, that we believe will have a long-term impact on nursing recruitment and retention. More on that to come.
ALL of our team members are important, but we are clearly seeing the impact of the national nursing shortage on our direct patient care. It is an urgent matter, and we are keenly focused on it. At the same time, we are also looking at other clinical professions where turnover has recently become a problem, largely due to national shortages in those professions.
I am writing this letter to you solely for the purpose of giving you insight into what is happening within the healthcare industry. Our exit interview data shows that locally, our nurses are saying the same things that the national data suggest – patient acuity is higher, experienced nurses are choosing to retire, and new graduates are entering the profession and experiencing stress as they take on the responsibility of caring for sicker patients with multiple comorbidities and social determinant issues beyond what they feel their skills alone can handle.
Our local data also indicates that the largest driver of our nursing turnover during the past few months has been nurses below the age of 40. This is concerning, since it suggests that newer nurses are overwhelmed by the environment and need the additional support. Ballad Health is investing in this support, and we plan to take more steps to ensure they feel confident in the work they do. This will not occur overnight, but we hope the result will be a decrease in turnover, which will help us stabilize the workforce against what is a national tsunami impacting the nursing profession.
As a team member, if there is anything I could ask of you, it would be to continue showing appreciation and support to your fellow team members for what they do. We might have different job titles and duties, but we are all one family. Show compassion and empathy if a team member is having a rough day and be there for them if they need someone to talk to.
We have some amazing people here at Ballad Health who want to help others, and it is heartbreaking to talk to a nurse or frontline caregiver and hear that they are unsure if they want to continue their profession because of these structural problems. In the past, Ballad Health’s facilities have been able to withstand these external pressures, largely because of the commitment our nurses have shown to our region. I think we will get there again, but I must say with all honesty that this is the worst shortage I’ve witnessed in my 30 years of experience in the healthcare industry.
If you have any questions about our efforts, please feel free to contact me or any member of our leadership team.
In the meantime, thank you and God bless you for all you do to serve the needs of the people in our region!
Alan
Alan Levine
Chairman and Chief Executive Officer
Ballad Health
