Why has COVID caused a nursing shortage but a physician glut?

[skougess]

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Just found out today travel nurses are making $8k/weekly to work in the COVID era because there is such an insane shortage. Can anyone chime in on how nursing is in a severe shortage? It’s somewhat obvious why physicians have taken a hit with decreased volumes, but it would make sense that nursing would follow suit.

 

[Vandalia]

First, there are a lot of nurses who are not working. I don't want to be sexist (which means that I will be) but nurses tend to be female, tend to be married, and tend to have families. I know a number of nurses in this category who have decided not to work, or more specifically to not work inpatient units. The same is true for physicians, but to a far lesser extent. That of course does not describe every situation, but it explains why the inpatient nursing pool has decreased, while the number of working physicians essentially hasn't.

Second, and I will get killed by the hospitalist for this, the nursing workload per patient has increased more than the physician workload. Based on an N=1 - and I am willing to admit I and my source are wrong - the patients that had a ton of physician work (placement) but required minimal nursing care aren't nearly as prevalent.

 

[AMEHigh]

I'm not expert, but when things got bad here they pretty much had every single resident working throughout all the hospitals in all specialties. In addition, where I worked our service typically only had 1 attending on at a time and the cap was something like 15, but once covid came they had 2 attendings on at a time. So between pulling extra attendings and having residents work (pulled off of all other services) that pretty much covered a lot of the extra need for physicians. Although I believe there were some locums physicians as well.

There aren't really extra nurses doing residency to pull from and a lot of covid patients should ideally have 1:1 or 1:2 care if they're in the ICU if really ill.

I'm not exactly sure how things are going at non-academic hospitals, but I've heard a few friends say they've tried to make outpatient appointments with their pcp's for example and they've been told there are none available because their pcp has been pulled to do inpatient coverage.

I have also heard some nurses quitting because of the craziness that's going on and being treated poorly. This is just a guess, but I'd guess that more nurses than doctor's have quit over the past 8 months as well.

 

[Porfirio]

My wife’s friend is an ICU travel nurse. She makes very good money right now. And there does not seem to be an end for demand. A lot of it is tax free because of the housing stipend.

 

[scoKraz4]

My wife’s friend is an ICU travel nurse. She makes very good money right now. And there does not seem to be an end for demand. A lot of it is tax free because of the housing stipend.

This. Many nurses are leaving their hospitals for travel nursing to get paid sometimes double/triple what they make. And many nurses becoming NP's.

 

[Mushdoc]

It’s easier to increase a docs patient load than nursing load. A hospitalist can increase his list by 5 patients but a nurse can only take so many. Many hospitals do not operate at full capacity and need to bring extra nurses on when they fill beds but can just ask the inpatient teams to carry a heavier load

 

[turkeyjerky]

It’s easier to increase a docs patient load than nursing load. A hospitalist can increase his list by 5 patients but a nurse can only take so many. Many hospitals do not operate at full capacity and need to bring extra nurses on when they fill beds but can just ask the inpatient teams to carry a heavier load

Bingo. Nursing ratios are much more codified (by law in CA) and hence have minimal ability to flex up. A large proportion of covid patients require ICU or stepdown level care, even if not vented.

Also, it seems in my experience that there's been much more of an issue w/ nurses getting sick than physicians. Likely related to the amount of time spent in direct contact.

 

[dadaddadaBATMAN]

Bingo. Nursing ratios are much more codified (by law in CA) and hence have minimal ability to flex up. A large proportion of covid patients require ICU or stepdown level care, even if not vented.

Also, it seems in my experience that there's been much more of an issue w/ nurses getting sick than physicians. Likely related to the amount of time spent in direct contact.

And let’s not ignore the elephant in the room, which is that from day one of residency we are ingrained to not take sick leave unless we are vented in the icu.

It’s inappropriate, but I have zero doubt that docs are working with covid, where nurses are much more likely to call out.

 

[BAM!]

While I don't think it's all from RNs calling out sick, this problem has driven me nuts for years. We have a sick call process. The fact that the RNs don't astounds me. Their sick call process is to close down ED rooms when they call out sick. Unbelievable.

 

[Angry Birds]

While I don't think it's all from RNs calling out sick, this problem has driven me nuts for years. We have a sick call process. The fact that the RNs don't astounds me. Their sick call process is to close down ED rooms when they call out sick. Unbelievable.

Really? At my hospital, it's the opposite. The nurses have a call out system and the docs better show up unless they are vented in the ICU.

 

[GeneralVeers]

While I don't think it's all from RNs calling out sick, this problem has driven me nuts for years. We have a sick call process. The fact that the RNs don't astounds me. Their sick call process is to close down ED rooms when they call out sick. Unbelievable.

The same here. I'll ask "Why are we short staffed today?" and often is the answer is "Four nurses called out sick". There seems to be no backup plan or incentive to get other nurses to fill in. Patients suffer as a result of this nonsense.

 

[Siggy]

The same here. I'll ask "Why are we short staffed today?" and often is the answer is "Four nurses called out sick". There seems to be no backup plan or incentive to get other nurses to fill in. Patients suffer as a result of this nonsense.

Every single night I come on, "Doc, we need you to transfer people out of the ICU. 3 nurses called out and now everyone in the unit is tripled and we have patients boarding in the ED."

Yea... you're failure to plan ahead isn't going to be why I downgrade people I think needs the unit.

 

[cyanide12345678]

And let’s not ignore the elephant in the room, which is that from day one of residency we are ingrained to not take sick leave unless we are vented in the icu.

It’s inappropriate, but I have zero doubt that docs are working with covid, where nurses are much more likely to call out.

I swear with their point system sometimes they can just take a day off for no reason at my hospital.

At my residency, there was always a shortage because at least a few nurses called off everyday.

 

[dadaddadaBATMAN]

Every single night I come on, "Doc, we need you to transfer people out of the ICU. 3 nurses called out and now everyone in the unit is tripled and we have patients boarding in the ED."

Yea... you're failure to plan ahead isn't going to be why I downgrade people I think needs the unit.

This right here drives me bananas.

“Doc the hospital is getting full and the hospitalists (list has 16 patients 8 new) is getting overwhelmed. You have to start discharging them or transfer them out.”

Call transfer center: “yeah there are like 7 beds total in the region 3 of them are covid whatcha got.”

Meanwhile there are 40 patients in the 15 bed ed with 5 people saturating in the mid 80s that are covid +, a stroke, a nstemi, a multi system trauma from glf and a fuc*ing partridge in a pear tree (5 septic UTIIIIIIS).

Actual beds in hospital? 200 something. Actual staffing on a good day? 180. Staffing today? 7.

So which of these patients do we want to get blatantly substandard care today?

End rant

 

[evilbooyaa]

Seems like the way that IM fellows in cards or GI can get pulled to cover inpatient IM floors, or even cards and GI attendings are being pulled (again) to cover IM floors, it's time for hospital administrations to start pulling NPs to cover RN duties if they're having trouble staffing.

Won't hold my breath for that one.

 

[southerndoc]

Seems like the way that IM fellows in cards or GI can get pulled to cover inpatient IM floors, or even cards and GI attendings are being pulled (again) to cover IM floors, it's time for hospital administrations to start pulling NPs to cover RN duties if they're having trouble staffing.

Won't hold my breath for that one.

My health system is doing this very thing. They pulled nurse administrators (like our sepsis quality coordinator) out of their administrative duties 2-3 days/week and making them work as a clinical nurse. One is an NP and she will be working as a nurse -- not as a nurse practitioner.

We have the option for our nurse practitioners to work as nurses (our meaning our group's NP's).

I have to say that we as physicians can also step up to the plate. We can help the overwhelmed nurses out by starting our own IV's when we have a chance. No transporters to take people to CT? Have your nurses or you do it yourself to push a few patients over. We recently had significant delays in CT's because we found the techs were spending more time transporting patients than they were running the machines (we have 4 CT's in our department). When we took transport off their hands, it's amazing how quickly their throughput improved.

This is not going to get any better until the pandemic ends. Nurses are out because of contracting COVID, nurses are out because they're taking better pay from travel assignments, travelers aren't fully vested in the ED they're working in (they don't "own" it), etc.

 

[GeneralVeers]

I've often wondered why we as a group don't employ scribes as transporters, and basically our own personal techs. A rule in business is that you never perform a task that a lower-paid person could do.

One of the most annoying tasks is calling patients from the waiting room and putting them in a chair just to talk to them. We are doing all waiting room medicine now, so there is no way around it. The nurses/techs are not helpful with this task

 

[GassYous]

My health system is doing this very thing. They pulled nurse administrators (like our sepsis quality coordinator) out of their administrative duties 2-3 days/week and making them work as a clinical nurse. One is an NP and she will be working as a nurse -- not as a nurse practitioner.

We have the option for our nurse practitioners to work as nurses (our meaning our group's NP's).

I have to say that we as physicians can also step up to the plate. We can help the overwhelmed nurses out by starting our own IV's when we have a chance. No transporters to take people to CT? Have your nurses or you do it yourself to push a few patients over. We recently had significant delays in CT's because we found the techs were spending more time transporting patients than they were running the machines (we have 4 CT's in our department). When we took transport off their hands, it's amazing how quickly their throughput improved.

This is not going to get any better until the pandemic ends. Nurses are out because of contracting COVID, nurses are out because they're taking better pay from travel assignments, travelers aren't fully vested in the ED they're working in (they don't "own" it), etc.

That's how you end up with the dysfunctional ancillary services like those in New York City where it de facto becomes your job to transport patients and start ivs when you have doctor things to do.

 

[GeneralVeers]

That's how you end up with the dysfunctional ancillary services like those in New York City where it de facto becomes your job to transport patients and start ivs when you have doctor things to do.

Agree completely. Even calling patients from the waiting room is a step too far for me (but necessary atm). I refuse to transport or do IVs or other stuff. The more we do it, the more they will come to expect it.

 

[Porfirio]

The answer is to hire $7.25-$15.00 per hour part time (no benefits) workers to transport, not hire the $200-$250 per hour physician to transport.

I thought we had plenty of unemployed, low skill people during this pandemic? Hell, I bet a waiter would be awesome at patient transport job!

 

[bravotwozero]

Agree completely. Even calling patients from the waiting room is a step too far for me (but necessary atm). I refuse to transport or do IVs or other stuff. The more we do it, the more they will come to expect it.

You can't get your scribes to do that where you work? That's what we do here.

 

[Apollyon]

My health system is doing this very thing. They pulled nurse administrators (like our sepsis quality coordinator) out of their administrative duties 2-3 days/week and making them work as a clinical nurse. One is an NP and she will be working as a nurse -- not as a nurse practitioner.

We have the option for our nurse practitioners to work as nurses (our meaning our group's NP's).

I have to say that we as physicians can also step up to the plate. We can help the overwhelmed nurses out by starting our own IV's when we have a chance. No transporters to take people to CT? Have your nurses or you do it yourself to push a few patients over. We recently had significant delays in CT's because we found the techs were spending more time transporting patients than they were running the machines (we have 4 CT's in our department). When we took transport off their hands, it's amazing how quickly their throughput improved.

This is not going to get any better until the pandemic ends. Nurses are out because of contracting COVID, nurses are out because they're taking better pay from travel assignments, travelers aren't fully vested in the ED they're working in (they don't "own" it), etc.

You and I could, routinely, start peripheral IVs to assist staff because we have extensive EMS experience. I would posit that the average EP would slow things down, due to never being trained to do it, nor having done many to establish proficiency, nor having done them recently.

 

[dadaddadaBATMAN]

You and I could, routinely, start peripheral IVs to assist staff because we have extensive EMS experience. I would posit that the average EP would slow things down, due to never being trained to do it, nor having done many to establish proficiency, nor having done them recently.

At least with us I think the majority of us are pretty proficient. I’m the one who is asked to get access on the esrd cirrhosis mi maw. I can handle a young worried well iv, and honestly I can do it without us too.

I would probably just set up the machine next to a chair and call people over to stick and get basic hx. Almost did this the other day, and if my next shift is that bad I’m doing it

 

[southerndoc]

The answer is to hire $7.25-$15.00 per hour part time (no benefits) workers to transport, not hire the $200-$250 per hour physician to transport.

I thought we had plenty of unemployed, low skill people during this pandemic? Hell, I bet a waiter would be awesome at patient transport job!

I'm not saying make a habit of it, but there's no reason to not be a team player. One transporter was out after a syncopal episode with resultant head injury and another scheduled that night had COVID.

The NY dysfunctional situation is more a result of nursing labor unions and cultural habit than anything else.

 

[Siggy]

My health system is doing this very thing. They pulled nurse administrators (like our sepsis quality coordinator) out of their administrative duties 2-3 days/week and making them work as a clinical nurse. One is an NP and she will be working as a nurse -- not as a nurse practitioner.

We have the option for our nurse practitioners to work as nurses (our meaning our group's NP's).

I have to say that we as physicians can also step up to the plate. We can help the overwhelmed nurses out by starting our own IV's when we have a chance. No transporters to take people to CT? Have your nurses or you do it yourself to push a few patients over. We recently had significant delays in CT's because we found the techs were spending more time transporting patients than they were running the machines (we have 4 CT's in our department). When we took transport off their hands, it's amazing how quickly their throughput improved.

This is not going to get any better until the pandemic ends. Nurses are out because of contracting COVID, nurses are out because they're taking better pay from travel assignments, travelers aren't fully vested in the ED they're working in (they don't "own" it), etc.

Even before the pandemic the hospitals I've been at chronically understaffed the hospital. We'd have an entire unit closed during fellowship and the charge nurse was telling us that there were no beds because of staffing. For most of September and October my ICU had zero COVID patients... still there were staffing issues.

It's not my job to eek out an extra 1% stock gain for the hospital's share holders by taking on nursing duties. Now if it's a difference of life and death? That's one thing. However I want the nursing administration to feel the heat for their conscious decision to understaff the unit.

 

[RustedFox]

Yeah: "Not my job".

They (admins, etc) want us to do it all, but they won't listen to anything that we have to say regarding any issues relevant to us.

"With great power comes great responsibility?"
Okay, we already have the great responsibility; but no power.

 

[GeneralVeers]

I'm not saying make a habit of it, but there's no reason to not be a team player. One transporter was out after a syncopal episode with resultant head injury and another scheduled that night had COVID.

The NY dysfunctional situation is more a result of nursing labor unions and cultural habit than anything else.

Sorry to say but you are part of the problem. You are acting as an enabler for lazy nurses, and bad administrators. If you do it once, then they expect it all the time. I find this to be true with the ultrasound-guided PIVs. Once they know the doctors will do this, the nurses give up and demand it all the time.

I only call patients from the waiting room for the initial visit. I have to do this in order to get an exam to chart and get paid. Everything else I make the nurses and techs do.

 

[wareagle726]

I find this to be true with the ultrasound-guided PIVs. Once they know the doctors will do this, the nurses give up and demand it all the time.

Isn't that the truth. In residency I got reaaaaallly good as US PIVs and then it seemed like the nurses couldn't get an IV on a healthy 20yo. At my job now I only do US IVs on babies and ESRD. I digress, back to the original convo.

 

[Fart Daddy Smooth]

The same here. I'll ask "Why are we short staffed today?" and often is the answer is "Four nurses called out sick". There seems to be no backup plan or incentive to get other nurses to fill in. Patients suffer as a result of this nonsense.

Patients AND staff suffer. Work sucks when there's not enough staff. To make matters worse, it puts pressure on staff to come in sick and get the rest of the workforce ill.

 

[Brigade4Radiant]

How can you be a team player if you don’t own the contract and are not a partner? You are an independent contractor. Does anyone help you out with diagnosing and managing patients?

Yell at a nurse you are gone they get rid of you for consult and patient complaints or missing sepsis or having their door to doc time elevated.

 

[KnuxNole]

Patients AND staff suffer. Work sucks when there's not enough staff. To make matters worse, it puts pressure on staff to come in sick and get the rest of the workforce ill.

Plus the work will not get done or done sloppily when sick. Would you want sick doctors/nursing half assing things or have them call out and get some rest.

 

[Arcan57]

The same here. I'll ask "Why are we short staffed today?" and often is the answer is "Four nurses called out sick". There seems to be no backup plan or incentive to get other nurses to fill in. Patients suffer as a result of this nonsense.

It's designed that way. There are nationally ranked metrics for the amount of nursing resources it takes to move patients through the ED. My last admin position was with a hospital that mandated that nursing directors aim for the 25th% of staffing. So essentially to have each nurse be more productive than 75% of the nurses working in the ED in the US. So how did we form this elite squad? Experience? Nah, our average nurse was 18 months out of nursing school. Fantastic leaders? Nah, our charge nurse turnover was 88% over the 5 years I was there. Maximally efficient processes? We had a lot of LEAN and 6 Sigma workshops but still couldn't "pull to full" or staff an RN swing shift consistently. Keep scheduled available resources to the absolute minimum and expect everyone to just go harder when someone called out? Bing-bing-bing.

We had to largely scrap a tiered response model for surge capacity after we implemented it. Turns out that for 12-18 hours a day, every day our staffing put us at the highest tier (internal disaster, nurses can't go home, cancel elective surgeries, shut down transfers in, etc). Quality and redundancy come at a cost, and it's not a cost most hospital systems are willing to pay more than lip service towards. I definitely had my eyes open when the CFO was discussing a disappointing quarter where volumes fell off a cliff and we were deep in the red. And when I looked at the numbers, we were still turning a profit (net income was positive). It just was less of a profit than had been budgeted.

 

[Porfirio]

I definitely had my eyes open when the CFO was discussing a disappointing quarter where volumes fell off a cliff and we were deep in the red. And when I looked at the numbers, we were still turning a profit (net income was positive). It just was less of a profit than had been budgeted.

Cut till profit baby, and keep the cut when profit increases for extra bonus profit.

Christmas is coming, and daddy CEO/CFO needs the bonus.

 

[nexus73]

This right here drives me bananas.

“Doc the hospital is getting full and the hospitalists (list has 16 patients 8 new) is getting overwhelmed. You have to start discharging them or transfer them out.”

Call transfer center: “yeah there are like 7 beds total in the region 3 of them are covid whatcha got.”

Meanwhile there are 40 patients in the 15 bed ed with 5 people saturating in the mid 80s that are covid +, a stroke, a nstemi, a multi system trauma from glf and a fuc*ing partridge in a pear tree (5 septic UTIIIIIIS).

Actual beds in hospital? 200 something. Actual staffing on a good day? 180. Staffing today? 7.

So which of these patients do we want to get blatantly substandard care today?

End rant

just give all patients moderately substandard care

 

[robellis]

First, there are a lot of nurses who are not working. I don't want to be sexist (which means that I will be) but nurses tend to be female, tend to be married, and tend to have families. I know a number of nurses in this category who have decided not to work, or more specifically to not work inpatient units. The same is true for physicians, but to a far lesser extent. That of course does not describe every situation, but it explains why the inpatient nursing pool has decreased, while the number of working physicians essentially hasn't.

Second, and I will get killed by the hospitalist for this, the nursing workload per patient has increased more than the physician workload. Based on an N=1 - and I am willing to admit I and my source are wrong - the patients that had a ton of physician work (placement) but required minimal nursing care aren't nearly as prevalent.

Stating the fact that the majority of nurses are female, likely to be married and likely to have families is in no way sexist