In the midst of a worldwide pandemic, many uncertainties and changes have occurred in the way we live, work and operate. One of the most looming uncertainties in the current state of the economy is our workforce, and how we will ultimately move forward when COVID-19 ceases to stand in the way.
In February of 2020, just three months ago, the U.S. unemployment rate was 3.5%, a fifty-year record low, before soaring to 14.7% in April 2020 (1). With “Safer at Home” mandates and social distancing guidelines, many industries have slowed their operations or have been forced into a complete halt. Hospitality and retail are two of the most notable. As of April, the U.S. Bureau of Labor and Statistics reported that the number of unemployed persons stands at 23.1 million (2). As a professional in the staffing industry, the high unemployment rates and layoffs in industries of leisure due to COVID-19 were to be expected, albeit unfortunate. What has been most surprising is the staffing challenges healthcare is facing. “Employment declined by 2.5 million in education and health services in April. In health care, employment declined by 1.4 million, led by losses in offices of dentists (-503,000), offices of physicians (-243,000), and offices of other health care practitioners (-205,000)” (3).
As health officials and politicians prepare for the devastation COVID-19 could bring to the U.S., especially in large metropolitan cities, we saw urgencies in the staffing industry to support hospitals and critical care centers by bringing in additional nurses, who are concentrated in emergency departments and intensive care units. Hospitals feared that they would not have the resources necessary to care for the number of patients who would require treatment in a climate of an already existent nursing shortage. The American Association of Colleges of Nursing states that there will be a need for “an additional 203,700 new RNs each year through 2026 to fill newly created positions and to replace retiring nurses.” (5)
In recent months we have seen headlines splashed across the front pages of most news sources that read something like “Need for nurses is driving record pay as coronavirus nears its peak.”(4) Not only have states in the Northeast been hit hardest by COVID-19, but they have been paying record-high hourly rates for nurses too. Conversely, headlines of hospitals reducing staff due to low census are becoming more common, “Henry Mayo begins staff reductions, citing low hospital visits.” (6) The opposition of healthcare staffing reported in the media prompted me to reach out to two healthcare professionals for an inside look into staffing changes that hospitals and ambulatory centers are facing.
Interviewee 1 is a Clinical Pharmacist with 30 years of experience in the emergency department of the Level II trauma facility.
Interviewee 2 is a Registered Nurse with 32 years of experience in the emergency department before becoming a Family Nurse Practitioner in an outpatient setting. Both professionals work in a county in southern California that reported some of the earliest cases of COVID-19.
What changes have you seen in nursing and overall staff in your hospital since the beginning of COVID-19?
- Interviewee 1: Mandated reduction in nurses’ weekly shifts and pharmacists’ weekly shifts.
- Interviewee 1: As an emergency room pharmacist, scheduled shifts are reduced by as much as 62.5% and I have noticed my nursing colleagues in the emergency room have had their shifts reduced by 50%. I have also seen that most travel assignment positions are eliminated, resulting in those nurses being sent home.
- Interviewee 2: The outpatient setting makes up 50- 75% of healthcare, while inpatient treatment makes up the remaining.
- Interviewee 2: Outpatient/ambulatory staffing has been grossly affected, and impacts the entire ecosystem of patient care.
- Interviewee 2: Number of nurses and overall staff has been greatly reduced due to the minimization of elective procedures.
- Interviewee 2: Nurses and support staff have seen duty changes to shift staff to areas where they are needed.
What were the changes to typical operations and procedures?
- Interviewee 1: The elimination of elective surgical procedures has dramatically reduced hospital census numbers.
- Interviewee 1: Hospital census numbers and thus staffing requirements, depend on elective procedures to operate at full capacity.
- Interviewee 1: Also, emergency room daily census numbers have been reduced from approximately 230 visits to 110 visits daily.
- Interviewee 2: Patients are called ahead of appointments and screened for symptoms, if they are ill, they are directed to the nearest emergency room.
- Interviewee 2: Patients no longer sit in the waiting room; they are directed into individual rooms.
- Interviewee 2: Telemedicine has become the most prominent form of seeing patients for many providers. It has completely changed the landscape of outpatient appointments.
Has your facility imparted furlough or layoffs?
- Interviewee 1: Clinical staff (permanent) have not been furloughed or laid off but have had their weekly shifts flexed off.
- Interviewee 1: Non-essential personal have been furloughed or laid off.
- Interviewee 2: While no nurses have been laid off, they have been furloughed or have had their hours significantly reduced, mostly nurses who work in outpatient surgery and procedure environments.
- Interviewee 2: Other licensed and unlicensed support staff such as medical assistants, licensed vocational nurses, and administrative workers have been laid off and furloughed.
Have you seen any rebound in hiring or operations following layoffs?
- Interviewee 1: Operating rooms have now been given permission to ramp up on non-emergency cases by 50%.
- Interviewee 1: To reach 100% they must now re-hire traveling nurses.
- Interviewee 2: Too soon to tell in the outpatient setting. California adopted a phased reopening, which has dramatically impacted the access to practice and procedures in the outpatient setting.
- Interviewee 2: Telemedicine was an emergency allowance by Medicare, if they rescind telemedicine visit allowance, operations will resume a more or “new” normal. There is a lot of uncertainty in the ambulatory setting.
Have you seen any impact on patient care with reduction or changes in staffing?
- Interviewee 1: No there has not been an impact on patient care. Core staffing is still there to take care of the reduced number of patients in the hospital. The quality is there; the quantity is not.
- Interviewee 2: I have seen delays in things that are thought of to be routine ie vaccinations, physical exams, and routine procedures.
What are your 3, 6, and 12-month projections for staffing and normalcy of operations?
- Interviewee 1: All I can hope for is that we are back up to 100% capacity in as short of a period as possible.
- Interviewee 1: Many people are going without basic care and scheduled elective surgical cases that really need to come into the facility to have things taken care of.
- Interviewee 1: Priority is that patients in need of care that are not able to be treated currently can receive care.
- Interviewee 2: From the outpatient perspective, I think that for the next 1-3 months people will slowly come back for outpatient type procedures and visits as they become more comfortable with safety measures put in place.
- Interviewee 2: Outpatient surgical centers are beginning to reopen, however, they have to re-hire staff that have been laid off or furloughed. They must get equipment back up and running. Many things must happen to bring things back online.
- Interviewee 2: Barring any increase in COVID-19 numbers, by 6 months we should be back in the Fall swing where people are returning to school, a busy time in outpatient healthcare.
Do you see low patient census as a positive in any light?
- Interviewee 1: Yes, emergency rooms have some degree of unnecessary daily visits. Now, only the most severe are seeking emergency care.
- Interviewee 1: This protects staff and other patients and is in line with medical professionals asking the population to stay home unless needing treatment for something severe. In other words, we medical professionals go to work daily for you; we ask you to stay home for us if your condition does not require immediate care.
- Interviewee 2: More standardization of regulatory licensure for all levels of healthcare providers to allow more flexibility in staffing for disaster areas and high-impacted area on a more permanent basis.
- Interviewee 2: I think that there will be a more flexible staffing model so that nurses are not so specialized in one field that when the patient census is low and outpatient facilities are closed, they will be employable in essential areas of nursing.
- Interviewee 2: I hope that moving forward, regulatory and system changes will happen to allow the appropriate staff to go where the patients are.
Following my conversations with both interviewees, I conclude with one central theme in the healthcare staffing environment – hope. There is no doubt that all industries have been affected by the COVID-19 pandemic; healthcare is not immune. While hospitals in New York and New Jersey are struggling to fill their departments with nurses, and travelers are flocking to fight for the lives of patients, facilities across the country are laying off medical professionals due to low patient census. Permanent staff has been furloughed, travel nurses have been sent home, and non-clinical personnel find themselves in a position of unemployment.
One thing remains to be true. When operations begin to normalize away from a state of the pandemic, patients will need to be seen, procedures will occur, treatment will resume, and both hospitals and outpatient clinics will carry on caring for patients and fighting for the overall health of our population. Healthcare is essential and so are the people employed by the industry.