The U.S. Healthcare Labor Market: 2020 & Beyond

“The U.S. nursing shortage shows no signs of abating and, in fact, will only worsen; and the available pool of domestic nurses is just far too small,” says Dalton, Chief Nursing Officer of Health Carousel.

As a featured keynote speaker of the National Association for Health Care Recruitment (NAHCR) 46th Annual Health Care Recruiting Conference, Health Carousel Chief Nursing Officer, Earl Dalton, addressed the nursing shortage impacting our nation’s healthcare providers. Accompanied by Dalton was Arlene Sadoff, Director of Talent Acquisition for Sentara Healthcare. Together, these two leaders in healthcare shared their insights in their webinar session, “The U.S. Healthcare Labor Market, 2020 Edition” during the virtual event held on July 30.So what’s the solution for hospitals and health systems struggling with historic shortages? Add more coverage.

Dalton adds; “It is important for hospitals to rethink their talent strategy. Today in the USA hospitals are competing for the same (shrinking) limited RN resource domestically. Seeking RN talent from international locations is an innovative way to secure a hospitals future without stealing from one another.”

This help takes the form of hiring highly qualified international nurses to build out their ranks, as Sentara did for the first time starting in 2019. It wasn’t a decision the 130-year-old nonprofit healthcare system took lightly, Sadoff said, but it’s one that has been an absolute success.

“I did have some reservations about hiring foreign-educated nurses (FENs), and some of our nurse-executives did, too,” Sadoff said. “However, we did our research and knew we would be recruiting high-quality, highly educated people.”

An Innovative Approach

Headquartered in Norfolk, Virginia, Sentara Health System operates more than 300 sites of care, including 12 acute care hospitals, in Virginia and northeastern North Carolina.

Sentara has a diverse range of locations that includes large metro areas, small rural towns, beach areas and mountainous regions. Its centralized talent acquisition team, which hires about 500 nurses a year, has to be on the ball and creative, Sadoff said.

“If you work in talent acquisition, you have to be ready for change and very agile,” she said. “That agility is crucial because the U.S. healthcare system is a complex landscape with multiple competing factors creating an incredibly tough environment,” Dalton shared. “And the landscape isn’t predicted to get any easier to navigate anytime soon.”

Layered on top of an existing shortage of nurses is a looming need for even more of the care providers, thanks to a variety of factors including the aging of the U.S. population and the number of Baby Boomer nurses preparing for retirement. This so-called “silver tsunami” puts unprecedented pressure on the health system, Dalton notes.

In 2018, the “U.S. Staffing Industry Forecast” by Staffing Industry Analysts predicts that RN demand will grow by 13 percent over the next decade. Meanwhile, the American Association of Colleges of Nursing (AACN) predicted growth of 3.4 million needed nursing positions by 2028 – in addition to the current shortage.

Add to that landscape a U.S. population that has increasingly complicated healthcare needs, chronic conditions and co-morbidities. The result, Dalton said, is a troubling experience-complexity gap: an increasingly younger nursing workforce is handling an increasingly aging patient population with more demanding health needs. The consequences can be dire.One study found that 40 percent of new graduate RNs report making medication errors, and 50 percent of novice RNs report missing signs of life-threatening conditions. Numerous studies showing the negative consequences of insufficient nursing staffing levels, with a strong correlation between nurse caseload and patient outcomes.

Thriving through the shortage

How are hospitals & healthcare systems addressing the experience-complexity gap?

When examining mechanisms for change, Dalton explained there are two paths to close the experience-complexity gap:1. Accelerate the transition from novice to competent, and 2. Look at recruiting strategies. The former improves RN preparation and their transition to practice to more efficiently develop clinical competence; the latter maximizes the knowledge and skills of experienced RNs across the organization.

“Smart organizations – those that have the best chance of thriving in these circumstances – adopt both of those paths. Sentara Healthcare is one of them,” Dalton referenced, “constantly examining its practices in nurse skills development as well as its recruiting strategies.”

After making the decision in 2018 to hire FENs, the Sentara team explored the process for about a year, talking to multiple companies before choosing PassportUSA, Health Carousel’s international healthcare staffing agency. Sadoff and her team took an equally thorough approach to recruiting – reviewing videos from hundreds of nurses who had been qualified through the stringent PassportUSA hiring process; having them take an assessment Sentara uses for all its nurses to determine if they’re a culture fit; interviewing their top candidates and having them interview with nurse managers.“The process was surprisingly enjoyable, and has paid off,” Sadoff said. Sentara currently has about 100 FENs under contract through PassportUSA, and the health system’s managers give them high evaluation scores.

This parallels the experience of its other PassportUSA clients, Dalton said. The company has garnered more than 800 responses from Chief Nursing Officers and other administrators at its client healthcare systems over the years. Among other positive feedback, Dalton shared, “more than 93 percent of respondents said they considered the international nurses’ quality of clinical skills and competency to be average or better.”

At Sentara, only three of the 100 FENs have left their positions in the year-and-a-half since the arrangement began, which Sadoff said is much lower than its domestic turnover rate. While it’s too soon to know how many of the nurses will convert to becoming Sentara employees – the typical PassportUSA contract lasts about three years – Sadoff predicts it will be a high percentage of them, given the feedback from healthcare managers, the community and the nurses themselves.

This seamless temp-to-perm conversion reflects the experience that other healthcare systems have with PassportUSA. Dalton stated the majority of the company’s international recruits are offered – and accept – full-time employment from their host hospitals after their contracts expire. In fact, the company has an 86 percent conversion rate.

Many tools in the toolbox

“Bringing international nurses onto their healthcare delivery teams is an important tool in Sentara’s toolbox to ensure it’s adequately and capably staffed,” Sadoff said.

Both Sadoff and Dalton agree that international recruiting is just one of many necessary tactics in a multi-pronged strategy.

“There really can’t be just one strategy for your organization to win,” Dalton told audience members. Indeed, Sentara Healthcare employs a variety of strategies to ensure it meets demand and is always examining additional options.

The health system has added a dedicated campus recruiter; adopted video recruiting as a first step in the hiring process as a way to get job candidates ready for recruiters; and opened its recruitment process up to FENs through its relationship with PassportUSA.

“While there is also great need for certified nurse assistants (CNAs) and other care providers, most of the staffing challenges at Sentara Healthcare – as at most health systems – are around finding enough nurses,” Sadoff said.

Sentara also introduced a surgical rotation to expose young nurses to their specialty options. Because many available nurse recruits are new college graduates, Sentara created a program called the RN Adult Health Rotation Team (AHEART), which gives them the opportunity to work and learn through a variety of two- to four-week surgical specialty rotations before choosing their employment path.“The AHEART program is one tactic to help the experience gap that the entire U.S. healthcare system is grappling with,” Sadoff said.

Determining the way forward

As U.S. healthcare providers determine their paths forward, one patient care factor has proved not to have a correlation to life expectancy: healthcare spending.

Dalton cited studies showing that the U.S. spends more money per person on healthcare than any other country -- $7,960 annually -- yet ranks 50th out of 227 countries in life expectancy. A variety of reasons from political to lifestyle to access issues and many more influence those statistics.

“We’re No. 1 in spending by a lot,” Dalton said. “Many observers ask, ‘What are we getting in return?’” One thing that undoubtedly increases patient outcome is nursing staffing levels, and international recruiting is an important part of that. But over the last three years, immigration hang-ups have led to a backlog of qualified, educated and experienced nurses in other countries who have completed endless hurdles but await visa approval.

It’s estimated about 250,000 nurses abroad are interested in working in the U.S., and at least 15,000 are fully visa-ready. Some relief for the situation could be on the horizon as Congress considers the Healthcare Workforce Resiliency Act, which could speed up the journey for some foreign nurses.

It’s just one step among many that need to be taken to ensure that U.S. hospitals have access to the number of nurses they need to protect the lives of patients as well as healthcare providers.

After all, concludes Dalton, “a fully-prepared RN workforce continues to be the critical solution in healthcare.”

A recording of the webinar on The State of the U.S. Nursing Workforce: 2020 Edition will be captured and available for public viewing in communication to follow.

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