COVID and the nursing crunch

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Jon Kuppinger is making the best money he’s ever made. He also is taking antidepressants to help cope with off-the-chart stress levels.

A registered nurse, Kuppinger used to work in Strong Memorial Hospital’s cardiac unit, a job he loved. When the pandemic hit, Strong converted the cardiac unit to COVID-19 care. Kuppinger’s stress increased steadily, and his job satisfaction plummeted. Some months ago, he quit to take a higher-paying nursing job in Arizona as an independent contractor at an agency that supplies temporary health care workers known as travel nurses to hospitals and nursing homes. 

Kuppinger is one of a legion of nurses who have quit long-held jobs at local hospitals as the organizations continued to face unrelenting COVID-imposed financial pressure while their clinical staffs grappled with previously unheard of mental and emotional demands. He exemplifies a challenge that hospitals here and across the country face—a shrinking pool of nurses to cope with rising demand as the pandemic ebbs and flows but never goes away completely.

In the pandemic’s early days, the big stressors on U.S. health care systems were bed and equipment shortages. Nurses and doctors were hailed as health care heroes, and were widely lauded for continuing to work and unflinchingly face the scourge head on.

More than a year later, scores of nurses have quit hospitals, forcing the institutions to stretch existing staff by assigning more patients to a shrunken pool of nurses and to hire expensive temporary help to augment their depleted staff.

The current 25 percent turnover rate among Strong Memorial’s typically 3,000-strong nursing workforce is 33 percent higher than before the pandemic. 

“That’s huge,” says Karen Keady, the hospital’s chief nursing executive and a University of Rochester Medical Center vice president.

Turnover in the highest-stress areas like the intensive-care unit tops 25 percent, she says. Keady recently held an informational workshop for Strong’s physicians to explain why the hospital is so shorthanded. 

The problem is national. To a greater or lesser extent, it affects virtually every U.S. hospital. 

An old problem

The nursing shortage is exacerbated by the pandemic, but it is not new. Experts have been sounding alarms for years, warning that as a wave of baby-boom generation registered nurses starts to retire, strains would build on hospitals, which at the same time would be increasingly called on to provide more care to an aging population.

“Given the growing demand for health care services across a multitude of specialties, reports project that 1.2 million new registered nurses (RNs) will be needed by 2030 to address the current shortage,” states a May 2021 University of St. Augustine blog post outlining the nursing shortage. 

Karen Keady

The pandemic added to the problem, creating “a wave of artificial early retirements due to the extended period of limited access for both patients and staff to medical facilities. Overwhelmed frontline-working RNs have been running a constant risk of developing nurse burnout,” the post adds.

At Strong, says Keady, “when the pandemic first hit in 2020, we had a fair amount of people who decided to retire. Maybe they were going to retire later that year or next year, but they just decided, ‘I think I’m going to retire now.’ We saw that happen initially. 

“Then as the pandemic persisted, and we had a second wave (in December 2020), people who’d had taste of the pandemic and all that it required in terms of stress and moral distress who chose to make other decisions about where they would work. They didn’t necessarily leave nursing. They went to ambulatory settings (like) surgical centers. They went to places where they weren’t likely to encounter another COVID surge. What we really saw was high vacancy rates in acute-care areas, the ED, the ICU, the medical-surgical unit.” 

Meeting a challenge

A military veteran and married father of daughters then 10 and 18, Kuppinger, 52, worked as an EMT before moving to nursing in 2017. He says he chose the career paths he did partly because he likes the rush and heightened awareness a high-stress work environment demands. 

“I guess I’m kind of an adrenalin junkie,” he confesses. 

As the pandemic loomed in the spring of 2020, Kuppinger pronounced himself ready to meet COVID’s challenge with a soldier’s sense of duty and nurse’s dedication to care.

“I just think there’s a job to be done,” he told the Rochester Beacon in March 2020. “There is something a little bit heroic about adapting and overcoming and still facing things even though the conditions are not ideal.” 

As the pandemic wore on, tensions mounted and Kuppinger’s patience frayed. 

“Everything was very herky-jerky,” he says now. At Strong, it felt like “things were falling apart. There didn’t seem to be a clear understanding of what was going on. It was the fog of war. There was a lot of fear and confusion.”

After Strong converted the cardiac-care unit he worked in to an all-COVID floor, Kuppinger put in for a transfer multiple times. He hoped to go to the hospital’s cardiac-catheterization lab. Several times his transfer was approved, but something always came up to short circuit the move. Finally, partly lured by the “crazy money” he could make as a traveler, Kuppinger decided to quit and take the Arizona travel nurse job. 

Having to increasingly rely on travel nurses to fill staffing holes puts hospitals in a financial pickle.

“Because the prices (travel nurse agencies) are offering, the compensation is so lucrative, we have seen a number of nurses leave to become travelers,” Strong’s Keady says. “That forces us to bring in travelers from someone else’s organization to fill that gap. It causes issues financially. Over time, it’s not sustainable.”

Big hospitals like Strong, a more than 800-bed teaching institution, can survive such financial pressure, but smaller, outlying hospitals could be forced under, Keady believes. 

She says travel nurse agencies charge Strong $170 to $180 an hour, about 65 percent to 75 percent of which goes to the travelers. The more than $100 an hour travel nurses make at Strong compares to hourly rates ranging from $37 to $42 the hospital pays its regularly employed nurses. 

Keady points out that employed nurses get benefits including health insurance, training and opportunities for advancement that travelers do not, factors she hopes will help Strong recruit and retain more regular staff. As part of an effort to retain and recruit nurses, the hospital has upped its employed nurses’ pay rate three times. It also recently held a recruitment event and plans to run more. 

For the time being, however, Keady admits, “we’re dealing with a fractured nurse force. We’re trying to stabilize it.” 

Kuppinger was generally happier in Arizona, where he worked three 12-hour shifts in a row and then got rotating days off. The schedule gave him opportunities to return to Rochester for visits with his family. He came back permanently to this area in June, however. 

Kuppinger says he would have stayed in Arizona longer and even toyed with the notion of relocating there. But his wife’s brother took ill in California. She went there to tend to her sibling and Kuppinger came back to Rochester to tend to their family. 

Expenses added by higher-paid travel nurses are far from the only financial challenge hospitals face in the time of COVID.

“Because hospitals stopped doing elective surgeries and patients stayed away from the hospital, hospitals had less income and needed to reduce staff to stay afloat. In response, many hospitals forced furloughs on their employees, leading some people to opt to retire who wouldn’t have planned to otherwise,” the University of St. Augustine post notes. 

Elective procedures include non-urgent operations like cancer, heart and gall-bladder surgeries. Such procedures can be vital to patients’ health but also are key profit centers for hospitals. Electives generate dollars that offset money hospitals lose on care delivered to Medicaid patients, whose government insurance does not cover the actual cost of care. They also help offset the cost of free charity care delivered to indigent patients as well as the millions of dollars hospitals typically write off annually for unreimbursed care delivered to uninsured patients who cannot or will not pay bills.   

When then Gov. Andrew Cuomo ordered area hospitals to halt elective surgeries in April 2020, the University of Rochester, which runs Strong and five other hospitals as part of its UR Medicine system, in addition to imposing an across-the-board 10 percent pay cut, temporarily furloughed a number of workers. The pause blew a half-billion-dollar hole in the university’s budget, UR officials said at the time.  

Almost at capacity

While staff shortages are recognized as an intractable problem across the state and country, Rochester hospitals are particularly pained. Monroe County hospitals, since the abrupt shutdown of the financially challenged Genesee Hospital in 2001, have been perennially packed full, typically running at more than 100 percent capacity on any given day.

For years, local hospitals’ chronic over-occupancy was seen by their managers as a blessing and a curse. A blessing because high occupancy meant a steady stream of revenues that kept hospitals solvent and a curse because it also meant overtaxed emergency departments and heavy demands on staff. 

The pandemic added new strains to overburdened nursing staffs’ loads. At the same time, an influx of COVID patients forced reductions and bans on elective surgeries, forcing hospitals to curtail or virtually entirely forgo their most profitable procedures. The 2020 elective ban was eventually lifted, but in December Gov. Kathy Hochul announced a new ban on electives. 

Her executive order went into effect last month as COVID’s Delta and Omicron variants put new strains on hospitals. The bans halt elective surgeries at hospitals that are not sufficiently staffed to allow for 10 percent of their total staffed beds to remain free to accommodate patients who might flood the system in a COVID surge. Figures hospitals report daily to the state show every Monroe County hospital to currently not meet the 10 percent threshold.   

Rochester Regional Health officials did not respond to requests for comment for this article. In a briefing two weeks ago, RRH chief medical officer Robert Mayo M.D. reported that “capacity at the hospitals within Rochester Regional Health remains a challenge. It’s a day-by-day matter of work. ICUs are very full.”  

The situation has not changed. On Jan. 2, Strong reported that it was nearly full, with 690 of its 755 staffed acute-care beds occupied and 118 of its 126 staffed ICU beds occupied. On the same day, the area’s second-largest hospital, Rochester General, reported 465 of its 562 of its staffed acute-care beds occupied and 45 of its 46 ICU beds occupied. The trend for both hospitals had varied little over the previous seven days. RRH’s Unity and UR Medicine’s Highland hospitals were similarly packed. 

On Kuppinger’s return from Arizona, he took a month off to collect himself and then went back to work as a nurse. He did not go back to his old job at Strong but instead signed on as traveler. He is currently working Rochester General, where he is assigned to the cardiac-cath lab. On days off, he also works at Strong on a per-diem basis, an arrangement that pays more than he would make as regular employee but less than he makes as a traveler.

Rochester General’s nursing staff seems as stressed as Strong’s, if not more so, Kuppinger says. From what he can tell, patient-to-nurse ratios are markedly higher at Rochester General. Employed nurses at both hospitals are discouraged to see travelers like himself being paid hourly rates as much as three times higher than what they earn. Stress levels—including his own—are high.

“I resisted taking antidepressants for a long time,” says Kuppinger, who now regularly takes the anti-anxiety medication Lexapro. “But when I started asking around, I found out that everybody’s on something.”

Kuppinger’s current travel-nurse contract runs until April. He says he expects to sign on for another hitch when it expires, “if I can stand it.” 

Will Astor is Rochester Beacon senior writer. Data visualizations created by by Jacob Schermerhorn.

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