Today we are paying tribute to the heart of the hospital, the nurses. We are so fortunate to have so many incredible nurses in our healthcare system. They play such an essential roll in the comfort and needs of patients, as well as keeping the doctors and physicians informed of what needs to be done. They are efficient, and run the show 24-7.
The truth is, we don’t have enough of them. And the ones that we do have are overworked and under-compensated. With the cost of nursing school high, it makes it even harder to incentivize people to go into the field.
We need nurses now more than ever. But why do we have such a shortage of them? Well, it has a lot to do with economics.
Episode 7: In Nurses We Trust- In today’s episode, I speak with Dr. Rosemarie Aznavorian, Chief Clinical Officer of a hospital staffing company. She’s had over 40 years of experience in the hospital system, and also happens to be my mother-in-law! We learn:
This was an incredibly insightful episode. For one, nurses are on the frontlines risking their lives every day to keep us safe. We should do our best to protect them physically, as well as financially. A huge thank you to all nurses working the frontlines!
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MESH VO: Hi everyone, Mesh here from Talk Money, and welcome back to The Price of a Pandemic, our series where we discuss how the coronavirus is affecting the economy, business, markets & investing.
If there’s one thing we’ve learned from this pandemic, it’s that we owe our healthcare professionals a lot. In the past few weeks, they’ve continued to go out into an unsafe world every day, showing up at hospitals with too many patients and too little protective gear. And when they finally go home, they sacrifice hugs and closeness in order to keep their own families safe.
At the heart of that team are the nurses. They attend to patients 24/7, a challenge even in calm times, and right now, hospitals are severely understaffed. In a time when masks and machines are limited, the risk of resurgence is high, and nurses are overworked, underpaid, and doing their best, how can we continue at this pace? In today’s episode, we talk about the increased demand for nurses - and why we have such a limited supply in the first place. I talk with Rosemarie Aznavorian, who served as VP & chief nursing officer in both a large multi hospital system and healthcare staffing company. She also happens to be my mother-in-law. Let’s get started.
Rosemarie: [00:00:36] My name is Rosemarie Aznavorian, and my current position is vice president and chief clinical officer. I've held that position in both the hospital setting as well as a healthcare staffing company.
Mesh: [00:00:31] And Rosemarie, can you explain to us what one of these staffing companies does?
Rosemarie: [00:00:56] Staffing companies are really a supplemental strategy [00:01:00] for staffing relief at the individual hospitals. [00:01:03] The hospitals could be expanding or opening a new service a cardiovascular service line or a neurological service line. They might need additional staff related to the number of FMLAs or it could be related to a large surge of patients whether it's the seasonal flu or whether it's related to the pandemic that we're going through now.
Mesh: [00:01:24] And in the case of the pandemic right now, I'm assuming you're seeing an // uptick in requests from nurses.
Rosemarie: Yes, absolutely. The requests were always there prior to the pandemic. And // COVID // has provided almost a 60% increase of requests from hospitals nationally.
Mesh: [00:01:58] And you yourself are a nurse. Correct?
Rosemarie: [00:02:07] I've been a nurse since 1979 // quite a long time ago. I decided to follow the leadership track, although I did a lot of clinical bedside nursing and specialties. However, I progressed to a manager, then to a director and then to a chief nursing officer.
Mesh: [00:02:38] And how long did it take you to become a nurse in terms of schooling and practice?
Rosemarie: [00:02:34] So I did start as an associate’s degree nurse and then went back and got my bachelor's of science and nursing, my master's of science in nursing administration, and then my doctorate [00:03:00] in executive nursing practice.
Mesh: [00:03:25] With all your experience, you probably have some good insights into how the hospital system works. Can you explain to us how the current system works in terms of staffing nurses?
Rosemarie: There are different ways that hospitals can determine the number of nurses that they need to take care for the patients that they have within the hospital that they're providing services for. [00:03:26] One of the most [00:03:30] common is referred to as HPPD, which stands for hours per patient day. There's also a national benchmark such as NDNQI, which is the national database for nursing quality indicators. [00:03:50] But all of those things, no matter which tool is being used, helps to determine how many nurses you need based upon how sick the patients are that you need to provide care for. [00:04:00]
Mesh: [00:04:26] And you mentioned to me before that they are [00:04:30] essentially two teams of nurses. You have a core team, but then you have a float pool. Can you explain the difference between the two?
Rosemarie: [00:04:15] Core staffing is routinely the amount of staff that are based at the hospital and based on a particular nursing unit. So the hospitals will staff in core positions on the average daily census. So if their average census might be eight, even though it's a 10 bed unit, they'll core staff to have a number of nurses available to cover those eight patients. [00:05:29] It's when their acuity or how sick the patients are increase, or if they get to full bed capacity, then they're going to need additional nurses over and above what is considered their core staffing. So many hospitals may actually have a float pool, which depending on whether it's a multi-hospital system or whether it is a standalone hospital, they may have a group of nurses that [00:06:00] float between different units. And those are the nurses that are considered supplemental staffing that they would work across the system where they're needed. So staffing agencies can provide [00:06:30] professionals from actually across the country. With everything that has been happening in New York, obviously New York had significant needs. Staffing companies have the infrastructure to be able to have nurses coming from other states, get them credentialed, get them competent, tested, and get them to the individual states or the individual hospitals that need them across the country.
Mesh: [00:08:35] And for a nurse to decide whether they want to be part of a core team or part of this float pool, it seems that there's better pay as a floating nurse or as, as a nurse that's part of a staffing agency or floats around. How do people make that decision?
Rosemarie: [00:07:29] Routinely in order to be part of a float pool you have to have a number of years of experience of independent practice. [00:07:42] Usually two to three years of being on your own because you're being put into an environment many times that you may not be familiar with. So you have to be able to understand the clinical needs of the patient and understand the hospital's [00:08:00] geographics as to where everything is. You have to know where the medications are. [00:08:03] You have to know the policies and procedures of the hospitals. So experienced nurses have the adaptability to be able to manage that. However, it is a mindset to be a float nurse and to be able to work across different hospitals or even take 13 week assignments. If you're working for a staffing company, you have to be able to be flexible. [00:08:25] There is routinely more of a financial incentive for nurses to be either in a float pool that's hospital-based or working for a staffing company. They're usually a higher level of base pay in a hospital. And those nurses also have the mindset, they're looking for flexibility to work within their schedule. So there are a lot of millennials that are doing the travel nursing so that they can experience other hospitals and other parts of the country.
Mesh: And [00:12:13] what are you seeing now in terms of the pandemic with all these hospitals requesting more nurses and I mean, they're putting their lives at risk. [00:12:23] What is the response from the nurses themselves?
Rosemarie: [00:09:40] COVID is extremely contagious and it's very easily passed along the ways that we have not experienced before. Many people are asymptomatic which means that they don't have any symptoms, but they still are shedding the virus and they don't really know that they [00:10:00] actually have it. That's what's called viral shedding. So the personal protective equipment or PPE that everybody's been speaking about, and you see all of the pictures of the staff wearing face shields, masks, goggles, head covers and foot covers. That adds to the clinical staff's challenges in not only protecting themselves, protecting their families when they go home, but also protecting the patients. The frontline staff is always experiencing some level of emotional as well as physical fatigue. When the patients are coming in significant volumes and they're getting sick quickly and having to go on ventilators very rapidly, and patients are dying with the virus and because their family members [00:11:00] can't be with that patient, it's many times that the nurses are the last person there with that patient. So there's a lot of burden on the patients right now in terms of trying to protect themselves and not have to go to the hospital.
[00:11:16] But there's also a heavier burden on the medical professionals in terms of being there for their dying patients.
Mesh: [00:16:45] That sounds insanely stressful. All these people putting their lives at risk. Can you [00:17:00] paint a picture for us on how understaffed hospitals are // and why they’re so understaffed?
Rosemarie: [00:11:50] In 2010, there was a report that came out from the Institute of Medicine and it was on the future of nursing. [00:12:00] And as far back as 10 years ago, it was clearly identified that we were going to be in a nursing shortage again
Mesh: [00:17:52] And how are we doing now?
Rosemarie: [00:12:11] We haven't progressed very well. There are a number of items that have led to the continued shortage. [00:12:22] The first is in 2009 where most of the recession had [00:12:30] occurred, a number of nurses went back into the workforce who might not have been working previously. Also, nurses who were getting ready to retire could no longer afford to retire because of the economic climate. So it gave a subtle but inflated confidence that the nursing shortage was not as significant as was projected in the Institute of Medicine [00:13:00] report. [00:13:01] So as the economy continued to improve those nurses started to retire and we were not producing enough nurses coming out of nursing programs. It created a significant vacuum, and a lot of the hospitals are competing for the same talent. So we really have not made significant strides in increasing nurses who are available to care for our patients at the [00:13:30] bedside.
Mesh: [00:22:34] And how important are nurses in the hospitals? I would love to have you share with us how essential they are to the whole system.
Rosemarie: [00:14:37] Although I'm a little biased, nurses truly are the foundational piece within any healthcare institution. [00:14:48] Nurses are there 24 hours a day, seven days a week with a patient. They're determining when a patient is deteriorating or when a patient is [00:15:00] progressing. They determine when a patient’s status changes and has to have a physician phone call made to determine what medication or treatment changes have to be done at a certain time. [00:15:12] And without nursing care, there's really no revenue generators for the hospital. Without nursing, you can't provide service to patients.
Mesh: [00:23:41] And so when you say revenue generating, you mean that the services // that these nurses perform is the services the hospitals charge the patients for.
Rosemarie: [00:15:30] Well, nursing actually is included in the room and board charge.
Mesh: [00:24:01] And what does that mean?
Rosemarie: So let's just say you're in intensive care and it's $2,500 a day to be in the intensive care unit. // Before you even get medications or treatments, or have a respirator or lab work. So the room and the board includes the nursing.
Mesh: [00:24:14] So is it fair to say with the cost of education, and then the amount of work nurses do and the amount of risk that they put their lives at, // and // comfort they provide to patients. They're not fairly compensated.
Rosemarie: [00:16:15] There's always room to have a much higher starting base salary for nurses right out of school. [00:16:21] If we had that, it would certainly keep a number of nurses in the profession. It would certainly help them in terms of repaying [00:16:30] student loans and helping to support their family. But even with physicians that are taking care of the patients, it's the nurses who are on the front lines. [00:16:41] And then it's nurses that [replace “is” with “are”] really the heartbeat of caring for patients.
Mesh: [00:25:46] And how do you think we can incentivize more people to go to nursing school? What would need to change so that it becomes more appealing and [replace with “so”] we could potentially solve [00:26:00] this issue of staffing?
Rosemarie: [00:17:04] There are a number of factors to consider. The first item would be taking a better look at how we could reduce or forgive part of the student loans. There's a number of ways that you can get some of that forgiven, but not everybody works within the federal system, so we need something a little bit more for the private sector. The second is to have the higher base salary for starting nurses.
Mesh: [00:29:00] And you had mentioned to me [insert “that”] there are restrictions state by state about where nurses can practice. How has the pandemic changed that and potentially helped?
Rosemarie: [00:18:19] Nursing licenses are either single state or what's known as compact license, and then the federal government in the VA has a different type of [00:18:30] licensing as well. [00:18:31] So single state licenses means that you have to go through their process of fingerprinting, getting your transcripts sent going through the vetting process to be able to get reciprocity of a nursing license, [00:18:55] If you're not taking boards directly in that state. A compact [00:19:00] license allows you to work within multiple states.
Mesh: [00:32:06] And are we going to see that post-corona stay the same or do you think that they'll revert back?
Rosemarie: [00:20:06] So with the current pandemic, what has happened is a number of governors have issued emergency declarations waving the fact that you needed to have a license to work in their state. // So right now, I could send a nurse to a different state who doesn't have that state license because they would be accepting a Texas license or a [00:21:00] Florida license wherever they were originally based.
Mesh: [00:33:59] That [00:34:00] sounds like it would be a good step forward. [00:34:19] Given everything that nurses on the front lines are going through right now, nurse to nurse, what would you say to those nurses on the front line?
Rosemarie: [00:21:34] First and foremost, thank you. You've seen many of them going into work, throwing their gowns on, putting their face masks on. So thank you for putting yourself at risk, for putting potentially your families at risk and caring for these very, very sick patients in very, very high numbers. Second, please always do your best. Try to take care of yourself. We know it's difficult right now. You're [00:22:30] being asked to work a number of hours. A 12 hour shift may turn into 13 or 14 hours because your patients are sick and your care is not complete. And the fatigue can weigh very, very heavily on the staff when you're there and the patients are dying. [00:22:54] That never leaves you. But taking [possible to replace this with “take?”] time to celebrate those patients that have recovered [00:23:00] and celebrate the reuniting of their families [there are hospitals who, when a recovered patient is being discharged, they play the Beatles song Here comes the sun so that everyone in the hospital knows that we have a recovered patient.]
MESH VO: The tension between reopening the economy and managing the pressure on our hospitals marches on. The one thing that’s clear is that our healthcare system wasn’t built to support this kind of widespread illness. And now that it’s more strained than ever, healthcare workers are paying the price. We owe it to our nurses to take care of them like they take care of us. How do we create better incentives for people to enter the field, and how do we remove financial barriers that deter desperately-needed students? How do we compensate them for putting themselves in harm’s way?
At the very least, we want to continue to show them gratitude for taking on an outrageous risk to serve the greater good. We can join the worldwide cheers each night to salute all the essential workers. We can take a minute to think about what we owe to nurses everywhere, and clap a little louder.
I want to thank Rosemarie Aznavorian for her time and sharing her insight into this industry.
This episode was edited and produced by Olivia Briley & engineered by Maia Tarrell. Our music is by Blue Dot Sessions. Sign up at thetalkmoney.co m for further deep dives and to hear other episodes. We appreciate you sharing this with your friends, and of course subscribing to us on Apple, Spotify, or wherever you choose to listen. Until next time.