Nursing’s New Normal

Shortages, increased responsibilities and different demographics change the profession of nursing

Of all the occupations affected by the pandemic, perhaps none was affected more or in more ways than nursing – which was already suffering before the first COVID patients started arriving at Georgia hospitals in March of 2020.

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Primary Care: Ashley Blackmon, president of the United Advance Practice Registered Nurses (UAPRN) of Georgia: photo Daemon Baizan.

“There was a shortage before the pandemic, but the pandemic was like fuel on the fire,” says Matthew Caseman, CEO of the Georgia Nurses Association. “It’s impacting all areas of healthcare.”

Exhausted, burned out and fearful for the health of themselves and their families, many nurses chose to leave for safer employment options during the pandemic. Others, approaching or reaching retirement age, saw the pandemic as a good time to leave the workforce altogether.

Certainly, the nursing shortage is the major issue in nursing today, says Caseman. But other trends, such as retiring baby boomers, have led up to or contributed to the shortage, while others – such as accelerated programs to train second-career nurses – offer hope to help relieve it. Still other changes – nursing teams, virtual nursing and increasing authority for advanced practice nurses, for example – alter the way nurses operate and may be key to improving patient care.

Safety Is a Top Concern

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Safe Staffing: Matthew Caseman, CEO of the Georgia Nurses Association: photo Daemon Baizan.

While discussions of nurse safety during the pandemic focused largely on the dangers of exposure to the coronavirus and the need for personal protective equipment, many nurses were – and still are – concerned about protection from another danger: workplace violence. In a 2019 survey by the American Nurses Association, one in four nurses reported being physically assaulted on the job. A survey this year by the American Nurses Foundation found various forms of workplace violence remain a top issue for nurses.

“There was a shortage before the pandemic, but the pandemic was like fuel on the fire. It’s impacting all areas of healthcare.” Matthew Caseman, CEO of the Georgia Nurses Association

“We have stories of nurses being kicked, pushed down, spit on and, of course, abused verbally by patients and even families,” says Caseman.

In May, Gov. Brian Kemp signed into law a measure designed to make hospitals safer places for nurses and other healthcare workers. The Safer Hospitals Act increases criminal penalties for anyone assaulting a healthcare worker on a hospital campus. It also allows hospitals to establish their own police departments similar to those on college campuses, allowing quicker response times in the event of assaults and other crimes.

Caseman hopes the increased focus on safety will give nurses some peace of mind. “Safe staffing is a huge issue with nurses in hospitals,” he says. “You are not going to stay on the job if you don’t feel safe.”

Nurses’ Primary Care Role

Whether it’s at your physician’s office, an urgent care center or retail clinic in your local Walgreens, CVS or other pharmacy, you’re increasingly likely to receive primary care from a nurse practitioner. Even in the midst of the nursing shortage, experts believe these advanced practice nurses (registered nurses who have additional education, training and certification in a specific area of practice) may hold the key to improving access to care – particularly as the state faces the shortage of primary care physicians. This may be especially true in rural areas.

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Promising Solution: Monty Veazey, president and CEO of the Georgia Alliance of Community Hospitals: photo contributed.

According to the Kaiser Family Foundation, in 2015 Georgia had between 32,000 to 33,000 licensed physicians, approximately 11,000 of whom were in primary care, says Ashley Blackmon, president of the United Advanced Practice Registered Nurses (UAPRN) of Georgia. “The most recent data shows that there are only 24,000 licensed physicians in Georgia,” she says. “I don’t know how many are in primary care, but I assume it is much less than 11,000.”

During the same time period, Blackmon says, the number of advanced practice nurses in the state has grown from about 15,000 to 18,000.

Increasing that number even more – as well as their scope of practice – could help ease some of the healthcare problems faced by rural counties, says Monty Veazey, president and CEO of the Georgia Alliance of Community Hospitals.

Of Georgia’s 120 rural counties, 58 do not have a hospital and nine do not even have a doctor, Veazey says. Others have a single doctor approaching retirement age. “It’s hard to recruit physicians to rural areas. I think we are going to see more and more counties in rural areas without practicing physicians.” Clinics staffed by a nurse practitioner are a promising solution, he says.

But making that happen will require more than training additional advanced practice nurses. It will also mean giving them more autonomy and the authority, as nurses have in many other states, to practice to the full extent of their education and training, says Blackmon. Importantly, this includes the authority to prescribe a limited number of narcotics and other medications, says Veazey.

Despite the increasing role of advanced practice nurses in healthcare, Georgia is one of 20 states where advanced practice nurses cannot provide medication without a collaborative physician, says Blackmon. It is also only one of “a handful of states” that limits the number of advanced practice nurses that can practice in a protocol agreement, or in collaboration, with a supervising physician, she says.

More Men, Minorities In Nursing

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Diverse Population: Nursing students at Interdisciplinary Simulation Center at Augusta University College of Nursing: photo Augusta University.

While nursing has and continues to be a female-dominated profession, the number of men choosing a career in nursing has been steadily increasing in recent years. According to the U.S. Bureau of Labor Statistics, 13.3% of registered nurses in 2021 were men. At Augusta University College of Nursing, 20% of students enrolled in degree programs are men, says Tanya Sudia, dean of the college and associate vice president for Academic Affairs for Nursing.

“There has definitely been a big push in the past decade to be more open across gender lines and across socioeconomic lines in both medicine and nursing,” says Blackmon.

More men in nursing translates to more nurses, potentially. It also means a more diverse nursing workforce that better represents and identifies with the people they treat. “One of the big things we are looking at is how do we really diversify the nursing workforce to match the individuals you are caring for,” says Pat Horton, CEO of the Georgia Center for Nursing Excellence.

“At Augusta University, one of the good things we are seeing and are very intentional about is further diversifying our student population in nursing across all programs,” says Sudia.

“With regards to racial and ethnic diversity we have been seeing a trend of just under 40% [of students who identified themselves as diverse], and that is a really important trend for our university and the state as well, because we want our students to reflect the communities and the populations that they serve.”

More Flexible Working Arrangements

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Very Intentional: Tanya Sudia, dean of the college and associate vice president for academic affairs, Augusta Univeristy College of Nursing: photo Augusta University.

Nurses’ work schedules traditionally have been grueling and rigid, with long hours, late nights or overnights and often little flexibility for holidays or time off. Increasingly nurses are demanding flexibility – and increasingly hospitals are meeting those demands through alternative staffing arrangements.

“In the past [hospitals] had a large core group staff that might be 80% of your staff, and the other 20% were per diem and part-time, but today many are getting creative,” says Horton. In addition to full-time and part-time core staff, hospitals today are likely to utilize float pools, or resource pools of nurses to fill gaps in different parts of the organization; nurses hired through agencies to fill in on an as-needed basis; and travel nurses who come to the organization, often from out of town or out of state, to work for a contracted period of time, says Horton. Some even hire gig nurses, short-term contractors who work directly for the hospital, she says.

Travel nurses received the most attention during the pandemic, when many nurses left regular jobs and signed with travel nurse agencies for increased flexibility and higher pay. But sometimes their travel was just across town or to the very hospital they left. “I have heard of nurses leaving their hospitals where they have worked for a long period of time and being rehired by the same hospital as a travel nurse,” says Caseman.

While traveling nurses were intended to help hospitals cope with short-term staffing challenges, in some cases they made things more challenging, particularly for rural hospitals that were already struggling financially. Many nurses left staff positions to make more money as traveling nurses but ended up working at the same hospital they did before. So the hospital not only paid them a higher hourly rate, it also paid the agencies that placed them, said Veazey. “Our labor costs went up as much as 67% between the nurses and the agency fees we had to pay to fulfill those shortages,” he said. “Some travel nurses were making up to $240 an hour. This presented a problem because we could not compete with that,” he says.

While travel nursing continues to be a trend, Horton says she is starting to see that some nurses who left their hospitals to sign with agencies during the pandemic are returning to hospital staff employment, recognizing the benefits – including employment benefits – of working in a more consistent environment.

Entering Nursing Earlier – or Later

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Getting Creative: Patricia Horton, CEO of the Georgia Center for Nursing Excellence: photo Daemon Baizan.

As the shortage of nurses is predicted to worsen, hospitals and educational institutions are looking for ways to grow the nursing pipeline. While such efforts once focused on those making college plans, the trend now is to engage students – who have a dizzying array of educational and career options – earlier in the process.

A number of partnerships between health systems and community colleges are encouraging students to explore nursing and even gain training and work experience while they are still in high school.

Through dual-enrollment programs – which allow high school students to take college classes and earn both high school and college credit – students can become certified nursing assistants (CNA), or patient care techs (PCT). “Then you can help them along that career pathway where they can then become an LPN and an RN and then go on to their BSN [Bachelor of Science in Nursing], which is our desired goal – to get all of our RNs to have a BSN,” says Horton, who believes the efforts to attract new nurses should ideally begin earlier – perhaps much earlier.

“One of the things we’re looking at now is how do we even get into elementary school,” she says. “How do we expose students to the opportunities that would be available to them, so they get excited and they begin to prepare early?”

While more nursing students are getting an early start toward their careers, another trend is for nursing students to start later – often after years in a different career, says Sudia.

“We are seeing an increase in terms of second-career students that are coming into nursing,” she says. “Some may have been in another career for only a couple of years. For others it might be a 10-year or longer career in another discipline.”

Both Augusta University and Emory University offer intensive, accelerated master’s degree programs in nursing for second-career students who have a bachelor’s degree in a different field.

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Virtual Care: Group of nurses who are part of the new remote nursing program at Phoebe Putney Memorial Hospital: photo Phoebe Health.

“Especially for someone with a second career, they want to move through that quickly and get themselves back in the workforce, so we offer more accelerated tracks for them to do so,” says Sudia.

Several nursing schools in Georgia – including Albany State University, Emory University, Georgia Southwestern State University, Georgia State University, Kennesaw State University, Mercer University and Valdosta State University – offer accelerated BSN degree programs for people who already hold a bachelor’s degree in an unrelated field. An accelerated BSN program launched this year at the University of North Georgia for people with an existing but unrelated bachelor’s or master’s degree.

Technology and Teams

With many bedside nurses retiring and the remaining nurses overworked, many hospitals are turning to models using nursing teams or virtual nurses to deliver care.

At Northeast Georgia Medical System, for example, team-based nursing matches an RN with an LPN and a PCT (or CNA), says Brett Gaines, director of talent acquisition.

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Registered nurse Krishondria, Thomas, one of the “virtual nurses,” at her desk in a remote location where she can communicate with patients: photo Phoebe Health.

“[The team] allows for that RN to take on more of patient load without being stretched thin or sacrificing the safety for the patient, because the LPN is able to step in and assist in a lot of ways, due to their licensure, that a CNA can’t,” Gaines says.

At the same time, she says, “the tech is going to be taking care of the patients, from anything as small as ‘I need a cup of ice,’ to help them turn in the bed and making sure they are safe and clean.”

Phoebe Putney Memorial Hospital in Albany is taking a different kind of team approach, matching bedside RNs with virtual RNs in its new remote nursing program.

Virtual nurses are Phoebe employees who work in a remote group location and communicate with patients face-to-face via Microsoft Teams on an iPad brought to the patient on a rolling stand. Virtual nurses handle a number of tasks including admission assessment, discharge preparation, medication reconciliation and patient education.

Phoebe’s virtual nurses, who have an average of 30 years of nursing experience, are a team filled with knowledge and wisdom, says Kelsey Reed, the director of patient care, who holds a doctorate in nursing practice, and heads the virtual remote nurse program. “Many of them were facing that decision of ‘Do I want to retire from nursing? Do I want to consider a second career?’ when faced with that burnout at bedside,” she says. “This gave them a wonderful opportunity to still share their knowledge, share their wisdom and give great quality education to our patients, just in a different setting.

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A Virtual Approach: Kelsey Reed, director of patient care at Phoebe Putney Memorial Hospital, with an iPad used to allow patients to interact with a remote nurse: photo David Parks.

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