Common Sense

The Agency Trap

Issue: November/December 2022

Author: Andrew Mayer, MD FAAEM

Unless your hospital is extremely unusual, you have been dealing with the wave after wave of agency nurses coming through your emergency department and the rest of your hospital. Nurses are desperately needed everywhere and they seem to have disappeared. The bidding war of incentive pay, sign on bonuses, and other means of attracting nurses to our hospitals has reached insane levels and yet has not produced the number of nurses needed to staff our hospitals. Many hospitals have closed beds due to understaffing and surgeries are delayed. The level of patient boarding in emergency departments is untenable. Every hospital administrator is frantically trying to scour the Earth trying to find any available nurse. Nursing shortages are not new but it seems Covid has pushed us over the brink to a new and unsustainable level.

American health care goes through cycles of an adequate supplies of nurses to times like now of extreme shortages. This current cycle seems different to me as more and more nurses are opting out of bedside care. Is this just Covid? Certainly, no one can blame an older nurse with health issues from deciding not to go into the Covid pit. Many nurses, especially more seasoned ones have decided to fill one of the ever-expanding number of quality and administrative jobs which have bloated modern health care. More and more of our experienced middle and late career nurses leave clinical nursing for the allure of regular hours and no bedside care. Their work product instead of direct patient care is meeting attendance and reports which closely monitor compliance with the ever increasingly burdensome quality and patient satisfaction requirements. Their efforts validate their salaries as they continue to bludgeon the few remaining bedside nurses into submission. I believe that instead of improving quality these nurses have helped lead to the highest levels of dissatisfaction with clinical nursing which I have ever seen.

Also, many of our best and brightest new nurses quickly decide to go to one of the plethora of often online nurse practitioner programs further depleting the supply of experienced nurses. Nursing schools are also in trouble due to a lack of an adequate number of faculty. The rapidly rising salaries for travel and agency nurses have depleted nursing school faculties preventing many from increasing nursing school class sizes even though they are desperately needed. This combination of threats to our nursing labor supply has pushed us to the brink.

Hospitals cannot pay a big enough sign on bonus to attract an adequate number of regular nursing staff. Brand new nursing school graduates are bid over and can work almost anywhere they chose. Any rules about new graduates needing experience before working in an emergency department or critical care setting have been discarded as almost any warm body who can click on a mouse in your electronic medical record will do. Hospital administrators are often left with no choice but to pay whatever a nursing agency asks to provide nurses to the hospital. No concern can be considered related to what hospital is losing this nurse used to fill the gap in your hospital’s schedule. This same nurse will be recruited to another hospital when their contract is up perpetuating the arms race which is the current state of American nursing recruitment.

The expanding use of agency nurses has been a catalyst for a further worsening of the already low morale of the remaining full-time nursing staff. Remember that these nurses have lived through Covid and were the ones who spent the most time in the rooms with the sick and dying Covid patients. They were the ones most frequently helping the dying say goodbye to their families who were not allowed in the room let alone the hospital during Covid. During all of this, they had been required to stretch their nurse to patient ratios to frequently unsustainable and unsafe levels. These same nurses have also been hit with call-offs and less scheduled shifts during Covid when patient volumes have plummeted and were then later asked to work multiple overtime shifts when the next surge arrived. Does anyone fault any of these nurses for leaving nursing or chasing the agency money?

I have seen wonderful long term skilled and dedicated nurses become totally disillusioned when they are forced to work with agency nurses. Like all groups of people, the range of skills and dedication of agency nurses runs all over the spectrum. Some are wonderful and remind me of military family members who are used to moving to new places and quickly fitting in and learning the ropes. They quickly become part of your team and then one day they have disappeared and are replaced by a new face. On the other end of this quality spectrum, there are many who are simply chasing a big paycheck and have little interest in joining even temporarily your care team. Every nurse like every person has a unique story as to why they are willing and able to chase the travel and agency money. Some are young and love seeing new places and delight in having a much higher income than they ever expected out of nursing. No one can blame them for this. However, some of these nurses will endlessly ask how things are done. They cannot be blamed for not knowing when supplies are located or how a specific process is done at your hospital. Who do they ask but your tired overworked and burned out nurse who never left?

The remaining battle hardened full time nurses who have survived Covid and are dedicated to your facility are left holding the bag. They are required to answer the endless questions from the endless parade of agency nurses passing through your department. Also, when times are tough, we as physicians go to our experienced nurses for help because we can trust them to get things done. How would you feel in this situation? They know that our patients are sick and need nursing and they pitch in for the good of the patient and the department. At the same time, while they are frantically working usually without lunch or a break, they know that the agency nurse that they are stretching to help is making twice as much as they are at that moment.

We worry about our wellness and burnout as emergency physicians but nursing needs help now. How do we stop this unsustainable process where nurses from one state go to another to work for an agency while their nurses come to your state? Hospitals will not be able to sustain this level of expenditure on staffing. How do we attract new nurses and keep the ones we have from leaving the field? Money does not seem to be the answer. Nurses willing to work could work every day if they wanted and make a huge paycheck.

What are possible solutions to this crisis? I think that a hospital must make their nurses feel special and make them feel that they are a part of a team. They cannot be begged to work one week and then called off for work the next. These nurses are people with families who have bills and expenses which cannot be met if suddenly their ability to work is endangered. Our nurses need to know they have stability and support. They want lunch and scheduled breaks. They want security to protect them from dangerous and frightening patients. Our nurses are willing to pitch in and work extremely hard when a particular shift calls for it. However, they cannot be expected to work short every day without lunch while working beside nurses who are making double their pay. An administrator bringing a cookie or a T-shirt to them will not endear them to your hospital. Also, nursing administrations demanding higher patient satisfaction scores does not help. Administrators already know that the way to make patients happy is by seeing them promptly and admitting or discharging them within reasonable times. Administrators yelling at nurses for low satisfaction scores when they are caring for four boarding nursing home patients or violent psychiatric patients waiting days for placement will not be any more fruitful than yelling at the physicians. Nurses need our respect and support.

What ideas do people have to fix or at least slow down this crisis? I am a free market capitalist at heart but the market forces currently driving nursing are pushing health care off of a cliff. Something drastic needs to be done. The federal government has used executive orders to produce baby formula and ventilators. Could the federal government use its powers to staff our hospitals with an adequate number of nurses? I believe that this is a real national crisis and that action needs to take place. Could the Defense Production Act play a role in regulating nursing? I am sure many people would hate this idea and think that we need to let Adam Smith’s “invisible hand” guide the market for nurses. I certainly see this argument but I also see the weariness in our nurse’s eyes every time I start a shift. If someone does not intervene in some way, our situation will only worsen. What do you propose?

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