Texas hospitals hit by staffing crisis as burnout depletes workforce and COVID-19 surges

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Texas nurse Jenna Price gets half a dozen solicitations a day from hospitals and staffing agencies that want to pay her four times her current salary to leave her job at a suburban Central Texas emergency room and take a temporary assignment in another hospital that needs nurses.

“The money is ridiculous,” Price said.

Not to mention tempting — especially after the most traumatic year of her career on the front lines of the coronavirus pandemic.

In Texas, where hospitals are struggling with historically low staffing levels while hospitalizations from the COVID-19 delta variant are skyrocketing, nurses like Price are a hot commodity.

There are 23,000 more unfilled jobs in Texas for registered nurses than there are nurses seeking to fill them, according to a labor analysis by the Texas Workforce Commission.

“There's no pipeline of staff that we see ready to just hop in and start helping,” said Carrie Kroll, vice president of advocacy, quality and public health at the Texas Hospital Association.

Burnout is causing nurses of all specialties to leave the profession in droves — or to accept better paying nursing jobs in an increasingly competitive market, nurses and hospital officials say.

“Our workforce is fatigued,” said W. Stephen Love, president and CEO of the Dallas-Fort Worth Hospital Council. “These health care heroes have been at this for 18 and 19 months. Many of them are just leaving the workforce, saying ‘I can’t do it anymore.’”

Kroll said one hospital system in Central Texas reported a 25% turnover in the last year, far higher than average.

“We've had a significant number of people, [after] the first two waves, who just stepped away from the profession,” Kroll said. “It’s too stressful. It was really life and death.”

Now, a spike in the number of hospitalizations of mostly unvaccinated people due to the delta variant is again straining hospital staffs across the nation, making it more difficult for understaffed hospitals to transfer patients out or bring contract nurses in from other regions.

“In some cases, no matter what you’re willing to offer, it’s difficult to get the individuals with the right critical training and experience,” said Dr. Bryan Alsip, chief medical officer at University Health in San Antonio, which is experiencing a 10% shortage of staff. “The surge we’re seeing isn’t particularly regional. So those crucial resources are in demand in many states, not just ours, and they’re all facing the same challenges that we are simultaneously.”

The result is an overheated nursing labor market in Texas that some argue is paying nurses what they’re worth for the first time in their careers — but that, at the same time, threatens to shut out hospitals that can’t afford to compete for nurses.

“We’ve got to figure out how we slow that down because that's not good for any of us or for the future of health care,” Nim Kidd, chief of the Texas Division of Emergency Management, told the Tribune.

The situation threatens to lower both access to and quality of health care — and that’s a problem for everyone in the industry, health care officials say. No matter how many beds a hospital may have, it can use only the ones that have staff to cover them.

“If we don't have enough nurses, we close units,” said Joycesarah McCabe, chief of nursing at Goodall-Witcher Healthcare hospital in Bosque County, near Waco. “We close hospitals.”

Most Texas nurses who work full time at hospitals are paid around $75,000 a year, depending on the market, in line with national trends, according to the U.S. Bureau of Labor Statistics. But hospitals say they’re losing nurses who opt to become traveling contractors for much higher pay or who answer the call of bigger hospitals offering signing bonuses and other perks that competitors can’t afford.

“There’s a lot of competition for the same group of nurses in Dallas,” said Donna Richardson, chief nursing officer at Parkland Hospital in Dallas, the county’s 882-bed public hospital. “I can’t find ICU nurses [to hire]. I’m getting minimal response from the staffing agencies. During the last surge, we were more worried about equipment and [personal protective equipment]. This time, we’re more worried about staffing.

“I could add 100 beds if I had the staff to support it,” Richardson said. “The things that keep me up at night are staffing and worrying about having enough staff to take care of patients with the quality of care they deserve.”

And the state, which used federal relief dollars to flood Texas hospitals with highly paid supplemental staff last year, has stepped out of the staffing game, instructing local health and government officials to take the lead on hiring the nurses with federal dollars that are now coming directly to them.

It all comes at a time when Texas is recording nearly five times as many hospitalizations from COVID-19 than it was a month ago — with an increase of nearly 50% just in the past week — as the highly contagious delta variant sends more unvaccinated Texans to the hospital every day. New cases are up 92% since last week, and deaths are up 15% in the same time frame, state health officials said Wednesday.

The number of new confirmed cases has reached levels the state hasn’t seen since February, shortly after the deadliest peak of the pandemic thus far in Texas. Forecasters are predicting that without major social and behavioral changes, like widespread masking and social distancing, hospitalizations could reach new highs within two weeks — just as millions of unvaccinated students return to school in mid-August.

Gov. Greg Abbott has barred school districts and local governments from enacting new mandates or restrictions.

Price said her hospital diverted incoming ambulances to other area hospitals last weekend because it had reached capacity.

“That’s happened maybe five times in the 10 years I’ve worked there,” she said.

State stops sending relief staff to hospitals

Using federal relief funds allocated to the state, Texas spent $5.36 billion to send nurses and other health care personnel to facilities that were being overwhelmed with COVID-19 patients starting in April 2020. Hospitals grew to depend on those nurses.

From the hospitals’ point of view, it was a quick, easy solution during a crisis: no applications for funding or grants, no haggling, no time wasted. The state asked how many the facility needed, and the workers showed up.

The state contracted the nurses and personnel through staffing agencies at market rates — some 14,000 of them fanned across Texas in early February during the winter surge.

As the vaccination effort picked up steam in the spring, those nurses were demobilized as hospital numbers returned to manageable levels. The last state-supported nurses were pulled from hospitals in mid-May.

A month later, the national vaccine effort began hitting a wall of resistance, and the delta variant began to surge through the roughly half of the population that had still not been vaccinated against COVID-19. After reaching a low in early June, hospitalizations began to rise.

Hospitals and local officials appealed to the state for help again. Last Friday, the state informed cities and counties that it would not restart the state-supported nursing program.

Instead, they told local officials, the money — some $10.5 billion in coronavirus recovery funds allocated to Texas cities and counties by Congress earlier this year as part of the American Rescue Plan Act — is now in their hands to use where they see the most need, including contracting with medical staffing agencies to hire more nurses.

“Shortages in health care, whether it’s workers or commodities or supplies or bed space, it can be a matter of life and death. Nobody disputes that,” Kidd told the Tribune. “But nobody hires doctors and nurses better than hospitals do. It’s what they do.”

ARP funds spent before the end of September on expanding medical capacity can be reimbursed by the Federal Emergency Management Agency, Kidd said.

“A year ago, nobody [at the local level] had money to do any of this,” Kidd said. “I'm grateful to the Biden Administration and Congress for putting 10-and-a-half billion dollars into Texas cities and counties to address COVID response and recovery. That’s what we should be doing.”

But local officials criticized the move and accused the state of abdicating its duties at a time when Texas hospitals need help the most.

Kidd said “that’s just not true.”

“The doctors and nurses that are in the hospitals, that have been working their tails off, we’re very grateful for their service. I know they’re working hard, I know they’re fatigued, and they’re heroes in my eyes,” Kidd said. “We are not abandoning the people of Texas. ... What we're trying to do is to help make sure those closest and with the best possible solutions to the problems are the ones that are solving those problems.”

Bexar County Judge Nelson Wolff said his county, which has seen some of the sharpest spikes in hospitalizations in the state in recent weeks, will work directly with Kidd’s office to leverage the federal funds when it’s time to hire more nurses.

“We’ll have to do it on our own, but he’s agreed to be the conduit,” Wolff said.

Some critics of the state’s response said that decentralizing that program could waste time and add confusion to the process at a time when COVID-19 hospitalizations are outpacing resources at an alarming rate.

“Are there going to be 254 counties with staffing contracts? And how long will that take?” Kroll, of the Texas Hospital Association, said.

Kidd said he hopes hospitals will be able to increase their capacity and reduce the pressure on staff by returning to some of the strategies they used early in the pandemic like halting or limiting elective surgeries.

Such steps are already being taken by many hospitals, including those in Bexar County, where officials announced Wednesday that elective surgeries would be limited to patients who did not require overnight hospital stays.

“Pulling out all the stops”

Some hospital administrators say that even federal money can’t always cover the costs of staffing during a bidding war, and that sustaining that level of pay for the long term is not an option even for the systems with more resources.

The 25-bed Goodall-Witcher Healthcare hospital in Clifton can’t find anyone to even apply for their open nursing positions — much less accept jobs at the rate the hospital can afford to pay, said CEO Adam Willmann.

“People are just not looking at us,” he said. “I guess the only way I'm going to be able to get staff again is to let them get really tired at these big hospitals, and then maybe they’ll come back our way. I’m at a point where I can’t keep up with the Joneses if I want to keep my lights on.”

Willmann said the hospital’s nurses regularly receive postcards and texts from other hospitals and travel nurse agencies dangling signing bonuses of $15,000 to $60,000 to become nurses elsewhere, either temporarily or as full-time hires. Some of them move 30 miles away to Waco for pay that is several times the standard rate, he said.

“How is that sustainable, even in these large systems?” he said.

It isn’t, said Richardson, the chief nursing officer at Parkland Hospital in Dallas. She said nurses in general have historically been paid below their value, “but you can only go so high on salaries and there's a cap to it. It’s just like gasoline during a hurricane.”

At Titus Regional Medical Center in Mount Pleasant, employees are being offered higher bonuses to work extra shifts in the COVID unit on their days off, and the hospital is increasing its hiring bonuses and part-time wages to attract more nurses with free time and local ties, like retirees or school nurses, said CEO Terry Scoggin.

So far, he’s able to cover the 12 beds that are currently filled with COVID patients, mainly with the incentives for current employees, and he’s managed to hire a new nurse as well.

“We’re definitely pulling out all the stops,” he said.

“A boom for nursing”

Like Price, Honny Pils is receiving increasingly large offers from recruiters desperate for her services.

Pils, a registered nurse in Franklin, a small town near Bryan-College Station, spent the past year working at hospitals in COVID-19 hot spots across the U.S. as a travel nurse, leaving her family for months at a time and making more money than she had in her entire career.

Pils said she’s sometimes awakened by memories of patients calling out her name. She had planned to take an extended break after her contract with a staffing agency ended in March. She wants to spend the next several months with family and concentrate on running her business, a local deli she opened before the pandemic.

But these days, her phone is lighting up with texts from staffing agencies offering nursing placements, both inside and outside of Texas, for $8,000 per week and climbing.

Pils figures that if the offers keep coming, she’ll soon be faced with one she can’t refuse.

“This is a boom for nursing. In all corners of the country, they’ve just been slogging along, working ungodly hours, under really bad circumstances,” Pils said. “It’s an astronomical amount of money in some ways, but in other ways I feel like it’s been earned.”

Disclosure: The Texas Hospital Association and Parkland Health and Hospital System have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.

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