The way forward: Coronavirus remains focal point for healthcare organizations

HealthLeaders: Now that the crisis phase of the coronavirus pandemic has passed, what are the primary clinical challenges that you are facing?

Janet Tomcavage: The biggest obstacle is staffing. It is a clinical challenge because we have had to close beds because we do not have enough staff.

The other concerning challenge is an experience gap. We are seeing fewer experienced nurses staying at the bedside. So, you have less nurses with at least 10 years at the bedside alongside young, inexperienced nurses who are precepting even less-experienced graduate nurses. Instead of having a new graduate paired with an experienced nurse who has been here 10, 15, or 20 years, now you are pairing a graduate nurse with a nurse who has only been here for three years if you are lucky. You do not have that wealth of knowledge that comes with experience. It is a big concern for me.

HL: How are you addressing workforce shortages?

Tomcavage: We have traveling nurses because we can have nurse vacancy rates on our medical-surgical units of 40% to 50%. So, we have leveraged premium labor in the form of travelers.

We started our own internal traveling nurse program to try to offer nurses higher payment rates to travel within our organization. We had a goal to hire 100 internal traveling nurses this year, and we are at 70, so we have made good progress. We have nine hospitals in our system, and we require our internal traveling nurses to work a 12-week rotation. We allow a break of 30 days in between rotations because travelers do not have to sign back up earlier than that traditionally. They get compensation for travel along with lodging if they must travel more than 60 miles one way.

We have opened up our staffing model for flex and per diem nurse roles because one of the things we heard from our staff is they wanted flexibility in the staffing model. We are allowing many more nurses to flex, which means they do not have set hours. The challenge with this situation is you are at the mercy of nurses signing up for shifts.

We have offered recruitment loans to new graduates and retention bonuses to nurses to stay with us. In the opposite of exit interviews, we are conducting “stay interviews” so we can understand what would keep people with us. We are looking at other retention strategies with benefits, the ability to work into a day-shift job, or reduced work on the weekends. The problem is you must have adequate staffing to do those things.

The big challenge is on medical-surgical units. New graduates want to work in specialty areas. So, we are trying to figure out how to entice people to work on medical-surgical units, but we are still looking for solutions.

HL: Now that we are in a new phase of the pandemic, what are your primary COVID-19 challenges?

Tomcavage: We still have about 100 patients with COVID in the hospitals, so we are not past the pandemic. We still have staff who contract COVID, so we are still dealing with that.

A main COVID challenge is we still have a lot of patients who have long-haul COVID. We also are seeing the effect of people who stopped receiving care during the pandemic who are now coming to the hospital with higher acuity in their conditions.

The primary COVID challenge is continuing to keep the communities focused on the virus. People need to get their boosters and take precautions because COVID is still out there. We need to stay diligent about community spread of COVID.

HL: In the next year, in what areas would you like to launch nursing initiatives?

Tomcavage: We have plans to kick off a virtual nursing model. This could be a fit for some of the nurses who have left the bedside because of the physical demands of inpatient work such as lifting patients and being on your feet through a 12-hour shift. We want to see whether we can engage experienced nurses to provide mentoring and to do admissions and discharges virtually. We are looking at a virtual model to help address the experience gap. We are looking at a pilot to get a virtual nursing model rolling.

A second area we are working on is team-based nursing. We want to convert from a primary nurse model to a team-based model. That team may be an LPN, an RN, and a nursing assistant, or it may be two RNs working together. The goal is to care for a group of patients versus a primary nurse with five patients. We are also looking at non-licensed nursing roles in team-based care.

We are also looking at how we can increase the market for nursing. We are working with local schools—both high school and colleges—to see how we can get better-prepared nurse graduates coming out of school. We want nurse graduates to be working at the top of their license sooner.

The last area is behavioral health and safety. There are patients who come into the hospital with suicidal ideation and violent behaviors. We want to care for these patients. State and federal guidelines call for one-on-one care or patient companion roles, which has impacted the nursing team because we must pull nurses from the team to sit in a patient’s room. We are looking at whether technology such as video monitors can help in this area.

HL: Do you have any other insights on the way forward now that the crisis phase of the pandemic has passed?

Tomcavage: We need to think about the impact on emotional well-being that the pandemic has had on care teams. Whether it be at the physician level, the nurse level, or the nurse assistant level, it is a concern. We have got to continue to work on resiliency programs for our staff because this is not something you recover from overnight. They have worked extremely hard for almost three years. They have seen more loss of lives in the past two-and-a-half years than they have probably seen in their entire career. They have seen loved ones die. They have seen staff pass away.

Another area we need to think about is the significant increase in violent behavior in the healthcare setting. Patients and family members are verbally abusive and physically abusive. Every day, a nurse is being verbally or physically assaulted in our hospitals. We track all of the events. Thank goodness, the number of serious physical events is not that big, but the number of serious events is increasing.

Healthcare organizations need to look at ways to improve security and safety for our staff. Geisinger has done a lot of that work. For example, we have introduced emergency buttons, so if any staff member is in a room and a patient is getting out of hand or a family member is being inappropriate, we can touch a button and immediately it sounds at the nursing station and at our security office. Somebody comes to the room immediately. Sometimes, you can diffuse the situation quickly.

Workplace violence could make our staffing shortages worse. People are going to leave because they do not want to tolerate this behavior.