Focusing on strategies outlined in the US Department of Health and Human Services’ 2021 Health Workforce Strategic Plan, experts on workforce development shared their thoughts on addressing the statewide health labor shortage at the 2022 North Texas State of Reform Health Policy Conference in Dallas on September 27th.
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A panel comprised of Jenifer Tertel, North Texas Regional Vice President of Human Resources at Medical City Healthcare, Peggy Ceballos, PhD, Associate Professor of Mental Health Counseling and Higher Education at the University of North Texas, and Elizabeth Merwin, PhD, Executive Director of the University of Texas (UT) Arlington Center for Rural Health and Nursing discussed approaches the state could take to expand and distribute the health workforce to better meet demand.
According to the panel, the state had a shortage of 20,000 nurses in 2018, a number that has grown during the pandemic to far outpace demand. Texas currently has the fourth worst nurse to population ratio at 9.25 registered nurses (RN) per 1,000 residents. At current rates, the nursing gap is expected to reach 36,000 by 2025 and 60,000 by 2032.
One of the challenges to recruiting and retaining nurses has been the shift in wage expectations, as those in the profession have come to expect higher pay.
“[The pandemic] has created this escalated expectation of the wage rate and it is a daily issue,” Tertel said. “There [are hardly any days where] I’m not talking about nursing wage rates. And despite ongoing investment, my organization between last year and this year is $50 million in, and we still just cannot keep up.
The expectation of the nurse is, ‘I can go and make $181 an hour.’ The nurses in New York were making $250 an hour when we were in our various stages of the pandemic, but their expectation, it’s like they’ve had a taste of what it’s like to make that money … We’re just barely at the tipping point of being able to see some of that downward trend, but I don’t think it’s ever going to go back to what we saw in 2019.”
Similar gaps exist for the region’s mental health care professions as the pandemic drove up demand for counseling services. Ceballos said along with increases in adolescent suicide attempts, emergency rooms saw a 20-fold increase in mental health-related visits for children aged 5 to 11 during the pandemic, a 31% increase for older children, and a 20% increase in visits from uninsured children. Meanwhile, the lack of cultural competency among mental health care professionals was exacerbated by those workforce constraints.
“We need to start thinking about how we’re training the next generation of professionals that are going out into the communities on how they can better serve these underserved communities,” Ceballos said. “How we can continue to address legislation that can help us to meet the demands that are in the state of Texas for now. The other part is how we [train] our mental health professionals in integrated care [and to be] able to work with primary physicians and nurses. How are we going to be able to now really come together to the table and look at patient health holistically?”
The UT Arlington Center for Rural Health and Nursing, the nation’s largest nonprofit school of nursing, has been committed to growing its pre-licensure program but has been limited in the number of applicants it can accept by proportion of clinical rotations available across the state. Merwin said the center has been focused on the shortage of professionals in rural areas but advocated for more investment to build clinical capacity.
“We have hired 5 masters-prepared or doctorally prepared nurses in 5 big regions of Texas,” Merwin said. “Their job is to develop relationships with rural communities that perceive a shortage of either nurses or health professionals and would like to work with us on developing implementation of our programs that are online for didactic coursework, and in clinical agencies in their home communities or at least in driving distance … We could solve the pre-licensure Bachelor of Science in Nursing program with resources, hiring faculty, preparing more faculty through graduate programs, and finding ways to build clinical sites.”
In Texas, nurse practitioners are required by law to have a physician collaborator. Tertel called on the legislature to explore ways to take in more diploma and associate degree nurses and allow them to practice at the top of their licensure.
Merwin argued that solutions around nursing should not compromise the standards and requirements to a 4-year Bachelor of Science in Nursing (BSN) degree.
One solution Merwin and Tertel offered was for providers to target candidates earlier in the hiring process by negotiating with students in the final year of their undergraduate or postgraduate nursing program regarding the terms of their employment in exchange for tuition relief. Finances remain a barrier to graduation for many, and by targeting relief earlier, providers would have more control and leverage over contracting wage and service time with new graduates.
The panel also spoke to the lessons learned from the pandemic. The public health emergency forced health human resource managers to reevaluate team nursing models and look at alternative levels of care, utilizing licensed practical nurses (LPN), nursing students, and patient care technicians to support patient care collaboratively and in a more comprehensive way.
“There’s a little bit of a double edged sword with the LPN piece, because as we are all aging, and the demand for assisted living and nursing home care continues to increase,” Tertel said. “We’ve got to make sure that we’ve got those pathways to get those LPNs into that setting as well.”
The University of North Texas has revamped its counselor training programs for students in social work, rehabilitation, and mental health, including those working in public schools, to focus on trauma-informed interventions and multicultural competency in their clinical rotations.
“Our goal is to be able to continue to increase [holistic mental health care] in North Texas,” Ceballos said. “We’re doing the second study in our second year of the program. We have been collecting data, and it’s part of the program, and we’re hoping to see what the data shows 4 years from now, to see how much we have been able to have an impact.”
Medical City Healthcare opened up a series of employee assistance programs aimed at supporting nurses dealing with trauma and burnout, including a mental health care hotline and time and space for decompression.
“[Caregivers] have a clinical educator that they can call 24/7 when they get stuck into a clinical situation that maybe [they] don’t want to go to their clinical nurse supervisor about right away,” Tertel said. “In the moment, they can tell their friend. So creating those easy non-judgmental pathways that reach out, to text or phone call that mentor [who] helps [them] for that particular situation that they find themselves.
[Another option is] what we do in the hospital with compassionate rounds that doesn’t just focus on the patient for connected compassionate care but it is also for the caregivers. Now we have check-ins with our caregivers on a daily basis, and then if there’s a critical incident we do have critical incident response teams that come in to help address the loss of a patient, or a child in particular, so the staff can decompress.”