Earlier this year, patients, doctors, nurses and EMTs took 3-minute turns telling Tennessee officials what they saw happening inside their hospitals after two health systems merged to form Ballad Health.
The meeting in February has been the sole opportunity for people living in either Tennessee or Virginia to step up to a microphone and tell their stories on the record, and air their concerns about Ballad’s plan to reduce the level of emergency care at two hospitals.
Just as the hearing neared an end, Tyler Finocchio rose to speak. He was working then as a clinical care pharmacist in the emergency department at Holston Valley Hospital in Kingsport, Tennessee.
“I see physicians leaving every day. I see nurses leaving every day, and I’m leaving. And I can’t leave and have a clear conscience without trying to beseech you to not let this continue to happen,” he said.
Just a few days earlier, he said, a woman came into the ER.
“We had about a six-hour wait time. She waited about one hour before she told the receptionist that she would just rather go die at home. Well, four hours later EMS brought her in in full cardiac arrest. And she has now since passed away,” he said.
Ballad’s CEO Alan Levine did not attend the hearing. Afterward, he said there was more to that story, but privacy laws prevented him — and should have prevented Finocchio — from talking about a patient.
Yet the underlying point of patients waiting many hours for care at Holston Valley was true — but had little to do with the merger, Levine said, as the condition had existed previously. He said much of it is a national crisis — a shortage of bedside nurses — playing out locally.
When there aren’t enough nurses to care for patients safely, Ballad shuts down floors and units. Patients admitted through the emergency departments are left to wait for an opening on a floor, and when the emergency departments become overcrowded or have too few nurses, they, too, divert patients elsewhere or leave them for hours in the waiting room.
Levine said Holston Valley’s problems would be addressed, but stories piling up on social media say otherwise, as do Ballad’s own reports. More than 2% of people waiting in Holston Valley’s emergency room leave before they are seen, a rate twice as high as most of Ballad Health’s other hospitals. Those sick enough to be admitted wait on average more than seven hours for a bed.
Critics blame Ballad’s management for driving away nurses. Ballad says it is working to recruit and retain nurses, but warn that the problem could worsen in rural areas such as Ballad’s mountainous footprint in Virginia’s coalfields and Tennessee’s Tri-Cities.
For the past decade, labor reports have warned of a pending shortage of nurses nationwide. A report published in 2017 by the U.S. Department of Health and Human Services found that by 2030, the market for nurses will be a distribution problem rather than an actual shortage. The report said some states, such as Virginia, will have tens of thousands more registered nurses than it needs, while other states will be short by as many.
But even within states, nurses are not distributed evenly based on need.
Kenneth Cox, dean of Radford University’s Waldron College of Health and Human Services, said shortages already exist.
“In 2018, the U.S. Bureau of Labor Statistics estimated that by 2022 there will be a 1.1 million nurse shortage,” he said. “The American Nurses Association in 2018 stated there will be more RN job openings in the United States than any other job through 2022. The job growth rate for nursing is projected to be greater than any other profession through 2026.”
The reasons vary. Many nurses are reaching retirement age at a time when the population is aging and requiring more care. Younger nurses want more choices than traditional hospital shift work of nights, weekends and holidays. The types of jobs available to registered nurses are growing swiftly, as health care moves away from hospitals and more to outpatient and home care.
Cox said nursing schools are trying to keep pace by increasing pre-licensure class sizes and offering online and accelerated programs for working nurses who want to move into management, research and teaching.
Earlier this year, Carilion Clinic merged its Jefferson College of Health Sciences into Radford University, with the goal of doubling the number of graduates within a few years.
“So how do we do that? That’s the nuts-and-bolts question that everybody wants to know, and that everybody’s been trying to figure out,” Cox said.
There are two barriers: a shortage of faculty, and not enough clinical slots for student nurses.
“We turn away many, many well-qualified students every semester in our programs currently on campus, and we don’t want to do that. We want to be able to take the great students into our program, but in order to do that we have to have clinical spots for them, and we also have to have qualified faculty teach them,” Cox said.
Faculty must hold at least a master’s degree in nursing, and preferably a doctorate. Faculty-to-student ratios are low in nursing because teachers take students from the classroom into clinics.
“The board of nursing requires us to have one faculty per 10 students when we take them to clinical, so it can be a burden,” said Cathie Collins, head of the nursing department at the University of Virginia’s College at Wise.
Radford and Carilion try to grow their own faculty by offering financial aid for graduate education and programs that offer the required credentials.
But even when there are enough faculty, there aren’t always enough places to train students.
“We have to peel back the onion and say if we want more nurses, we have to provide more clinical space. The schools are limited by what the accrediting bodies count as a true rotation,” said Meg Scheaffel, Carilion’s chief nursing officer. “Why can’t somebody go for six weeks and treat patients in the mobile van? It’s starting to change, but that is in the future.”
Cox said that Virginia’s Board of Nursing requires students to complete rotations in pediatrics, critical care and obstetrics-gynecology, but they can look at some nontraditional clinical placements.
“But the students need to become competent to go out into the workforce and be entry-level nurses,” he said.
Collins said Ballad has worked with UVa-Wise to find slots for students in the small, rural hospitals.
“They’re great, but when you’re trying to teach students, they really need that big hospital, at least one or two rotations, to be able to get in there and get some good experience,” she said.
The closest opportunities are in the Tri-Cities, but she said Ballad reserves many of the available slots for students from East Tennessee State University.
“They sort of get first dibs, so that’s hard on a lot of other nursing schools, especially when we want our students to have those experiences as well. So I think some of that needs to be taken into consideration, because we all have good students,” she said.
In Roanoke, Cox said, Radford finds spots in other systems besides Carilion, and Carilion also takes on students from other nursing schools, with about 2,000 students each year.
For students, traveling can be a burden, especially in rural areas. Kim Dorton, dean of Mountain Empire Community College’s health sciences program in Big Stone Gap, has worked with Ballad and its predecessor Mountain States Health Alliance to increase the number of nurses who will stay in the region.
Before its merger with Wellmont Health System, Mountain States struggled to fill 16 nursing vacancies at Norton Community Hospital and eight others in neighboring Dickenson Community Hospital. No one was applying. Norton’s management reached out to Mountain Empire and UVa-Wise, and within two years had brought the vacancies down to four in Norton and two at Dickenson.
Ballad did not have nursing vacancy numbers for the former Wellmont hospitals in Norton and Big Stone Gap. It recently announced plans to consolidate the three Wise County hospitals and said it would add other health service lines.
“As Ballad eliminates some services at some locations, that has the potential to decrease some clinical slots,” Dorton said. “However, as they consolidate services, we are hopeful that will provide even more robust clinical experiences for our students.”
She and Collins said simulation labs are critical as they can offer students experiences they can’t get otherwise, but are expensive. Collins said Ballad could look to help with the costs.
Focusing on retention
Lee Lea, LewisGale Regional Health System’s chief nursing officer, said the first year of nursing is crucial for retaining nurses.
“Less than one year is when they are looking to leave, because they’re realizing exactly what they are getting into,” she said.
To overcome this, LewisGale began a program for Virginia Western Community College students to shadow nurses while still in school to find a good fit. Once licensed, they complete 12 to 14 weeks of orientation and then a year-long residency that was created to smooth any difficulties.
Mostly, Lea said, it’s about creating a culture for nurses to have a voice.
“I definitely find that with the newer generation, they want to have a say in decisions that are being made within the hospital and all the way down to the bedsides where they are providing care. So we have a shared governance model, which keeps nurses engaged in the decision processes and lets them have a voice in everything we do here,” she said.
Carilion also has a residency program for nurses. Scheaffel said they found leadership development and investment in nurses are key to keeping them.
“If they don’t feel supported and that someone is invested in them, if they don’t feel things are handled fairly, if there are cliques, they may not stay,” she said.
Carilion has lowered its turnover rate to below the national average.
“We have shared governance. Some folks look at it like a lot of meetings, but it’s really the voices of nurses,” she said, as they can opt to be part of committees working on technology, recognition, practice quality, education and research. “They weigh in on what they are doing, and I listen to the feedback.”
Carilion was the first health system in Virginia, and the 13th in the country, to be certified by the Forum for Shared Governance. Carilion Roanoke Memorial Hospital is among 2.5% of the nation’s hospitals to receive a fourth Magnet designation for nursing excellence from the American Nurses Credentialing Center. But that wasn’t always the case.
“A few years ago, we had nowhere but up to go, so we had work to do. We took on that challenge,” Scheaffel said. “We just didn’t fully understand what shared governance was. Leaders conducting staff meetings and talking at people wasn’t nurses driving and owning their practice. We had to flip the coin.”
LewisGale, owned by HCA, the nation’s largest for-profit health system, and Carilion, a regional nonprofit, have very different corporate structures but are responding in similar ways to hiring and retaining nurses.
“You have to be competitive. You don’t have to be top dollar. We will probably never beat what HCA pays, and they are just three miles down the road, but we are competitive,” Scheaffel said. “It’s the culture. With millennials, they want to be contributing to the organization.”
Both offer financial assistance for nurses to further their education. Carilion last year began to hire licensed practical nurses as part of care teams with the understanding they’d enroll in an RN program. Most have.
While LewisGale relies less on travel nurses than it used to, it still uses the nurses, hired through contract services, to fill in during busy seasons such as when the flu fills its beds.
Carilion created its own traveling nurse program, or float pool, for nurses who prefer contract work at community hospitals. This has helped to fill slots at its rural hospitals.
Carilion’s hospital in Tazewell is in the same region as Ballad’s Virginia hospitals. Scheaffel said Carilion cross-trained its nurses so that even if inpatient volume is down and fewer floor nurses are needed, they can take shifts as case managers or school nurses.
“It really takes creative partners and a different way of thinking. Maybe Ballad could establish a resource pool. They did it in Denver where they had seven hospitals hours apart, but they managed to float nurses. It takes time and organization,” she said.
Both Carilion and LewisGale have also found success with hiring international nurses, mostly from the Philippines, for two- or three-year contracts. Nearly all have stayed.
“They really integrate in the community, and as their contracts have ended they have joined us full time, and they’re rock stars,” Lea said. “They’re just very experienced, very good with communicating with their patients and connecting with them, and providing care, so that has been very exciting.”
Lea said the first international nurses were hired three years ago, and now LewisGale has more than 30.
Both systems are always hiring nurses. On any given day, Carilion has a hundred openings. But that’s fewer than before.
“We know we are on the right track. We had record-breaking recruitment years, and our turnover is decreasing, so two plus two equals five for us,” Scheaffel said. “We are going to keep doing these programs and measuring their effectiveness and if one isn’t working for us, we’ll think what else is out there for us.”
What’s next for Ballad
Earlier this year, Ballad moved all of its nurses onto the same scheduling system and reduced the salary layers that had grown under the legacy health systems. Although the intent was to not lower anyone’s pay, the number of shifts and hours worked changed for some nurses and created concerns among some that they would earn less.
To address turnover, Ballad in May announced it would spend $10 million on salary adjustments as one way to keep nurses from leaving the area — or the profession.
It still comes up short of staffing needs.
“If we don’t have enough nurses on a shift, in the interest of patient safety, we will close beds to minimize stretching the nurses too thin. Each shift, our nurse managers, themselves Nurses, must assess the severity of patients and made determinations about staffing levels,” Levine wrote in an email to staff in July.
“The primary importance is patient safety. If there are not enough nurses, it could be that a hospital will go on diversion in order to ensure we don’t over burden the nurses. This is inconvenient for patients and, of course, for EMS. It is never a preferred approach to go on diversion, but when it is necessary, it must be done to protect patients.”
He said they would add a scheduling tool to offer nurses more choices and flexibility, and they were looking for more ways that nurses could offer ideas to help with retention and recruitment.
“All indicators are that this problem is going to get worse, and not better,” he wrote. “And the worse it gets, the more opportunity there is for our incredible nurses to face burnout. We want to avoid this, and we need to be engaged together to identify solutions that work.”