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In rural areas, nurse shortage hinders fight against COVID-19
Fewer professionals makes task tougher
Published Sunday, June 14, 2020 7:00 pm
by Korie Dean | UNC Media Hub

A shortage of nurses in North Carolina's most rural communities hinders health professionals' ability to treat COVID-19 patients.

Growing up in rural western North Carolina, Rachelle Bradley always knew she wanted to enter a profession that would give back to the community where she grew up.

“I’ve had a love for nursing ever since I was a small child,” Bradley said. “I had very sick family members, so it made me want to take care of them, naturally.”

Now, Bradley is doing just that.

As an emergency room nurse at the only hospital in her home county, she is on the frontlines of the battle against the new coronavirus, or COVID-19.
While the virus had an early stronghold on large urban cities, like New York City, rural communities across the country, like Bradley’s, are now experiencing a rapid spread of the virus and the disease it causes.

According to data analysis by the Northeast Regional Center for Rural Development at Pennsylvania State University, the virus is “growing dramatically more rapidly” in rural areas than it did in metropolitan and urban areas at comparable stages. And for rural communities, which struggled to provide adequate health care access and services even before the pandemic, COVID-19 is straining resources that were already in short supply.

That strain is perhaps most evident in the shortage of nurses and skilled staff that many rural hospitals and other health care facilities are experiencing.

“The biggest obstacle facing the health care system overall is not finding rooms. It’s not finding beds,” said Mark Holmes, director of the North Carolina Rural Health Research and Policy Analysis Center. “It’s a lack of staff.”

The health care labor shortage isn’t unique to rural America. The Bureau of Labor Statistics predicted in 2016 that the country would need more than 200,000 nurses to enter the profession each year in order to replace the growing number of registered nurses that are reaching retirement.

But rural areas, with populations that generally have higher rates of chronic illness and larger elderly populations, are disproportionately affected by the shortage of health care workers.

“Basically, on almost any health condition, it’s going to be worse in rural areas,” Holmes said. “Whether those are stroke rates, motor vehicle mortality, diabetes rates, smoking rates.”
Now, as rural communities face the battle against the coronavirus, the effects of that shortage are being felt more than ever before.

‘This is a long-standing issue’
Bradley estimated that the rural western North Carolina hospital where she is employed, which she asked not to name, has more than 110 beds. The emergency room, the unit where she works, has about 25 beds. She estimated that, before the coronavirus, between 80 to 100 patients were treated in the emergency room each day.

Before North Carolina entered into its phased reopening, Bradley said that the hospital had a roughly 50% decrease in patient volume, with only about 40 to 50 people coming into the emergency room each day, and most elective procedures being cancelled.

Now, as North Carolina remains in its second phase of reopening, Bradley said that patient numbers are steadily rising, with about 60 to 70 people a day coming into the emergency room.

“People in the community have not been going to the emergency department for a toothache, a stubbed toe, a headache,” Bradley said. “They have actually stayed away from the hospital and only come in when it’s an emergency.”

But Bradley said that, even with a smaller-than-normal patient volume, staffing is still a major issue—just like it was before the spread of the coronavirus.

“This is a long-standing issue that has existed well before COVID-19,” Bradley said.

Bradley said that the hospital operated as a non-profit until it was bought-out by a for-profit entity in recent years.

As a non-profit, the hospital staffed its units by acuity, meaning that the number of nurses scheduled to work at any given time was based on the level of care and attention that each patient in a given unit required.

Staffing by acuity has been linked to decreases in patient mortality and other adverse patient outcomes, as well as decreases in the amount of time patients stay in the hospital.
As a for-profit institution, the hospital is now staffed based on patient census, or the total number of patients in the hospital, regardless of the amount of specialized care they need. That typically means fewer nurses are working at a given time.

“It doesn’t matter how sick the patient is. It doesn’t matter how many nurses they are going to require, how many resources such as labs and respiratory therapists,” Bradley said. “They don’t take that into account. So as far as staffing, it definitely has become an issue, because, in my opinion, you’re not meeting the needs of the patient.”

Bradley recalled that, about two years ago, her county experienced a particularly bad flu season. The number of patients became so overwhelming that the hospital had to divert ambulances away because they didn’t have enough staff to properly care for new patients.

“We simply did not have any place to put them,” she said. “We never had enough staff, even through the influenza, but we, as nurses, made it work. We didn’t have a choice.”

Now, even with a decrease in patient volume due to the coronavirus, Bradley said she thinks the hospital is still short-staffed, because a lower patient census means fewer nurses are scheduled to work at a given time.

“Staffing is an issue because we were short to begin with, and then when you have something as complicated as COVID-19, it requires at least two nurses per COVID patient,” Bradley said. “Realistically, it would be nice to have three.”

Before North Carolina began its phased reopening, most elective medical procedures were cancelled to prevent the spread of the virus. Bradley said that, in her hospital, nurses who work in the units that typically provide those procedures started working in the emergency room to support nurses and staff there.

But it still wasn’t enough.

“Because emergency room is considered a specialty, they cannot do everything an emergency nurse can do,” she said.

To give coronavirus patients the specialized care and attention they need, Bradley said the hospital considered developing a unit specifically for those patients—but the unit couldn’t open until they had two coronavirus patients on a ventilator or five coronavirus patients not on a ventilator.

As hospitalizations around the state continue to increase, Bradley said that her hospital still hasn’t had to open a special unit because they have not had enough critically ill coronavirus patients in the hospital at one time.

But, because the unit never opened, the staffing issues continued.

“It’s very, very hard on not only the nurses, but it’s very hard on the patient,” Bradley said. “And they’re not getting the care, the top standard care, that they deserve.”

The struggle to recruit
One reason for the shortage of nurses in rural areas is how difficult it can be to recruit outside workers to those communities.

Bradley chose to work as a nurse in her home county because she knew from her own experiences how badly the region needed health care providers.

“I’ve had offers to work at hospitals within a 50-mile radius, even a 100-mile radius,” Bradley said. “I chose my community hospital because I wanted to make a difference in my community.”

But some communities aren’t so lucky.

Audrey Snyder, an associate dean at the UNC Greensboro School of Nursing, is chair of the Rural Nurse Organization.

“If someone has an experience in health care in a rural environment, they’re more likely to go to a rural environment to practice,” Snyder said. “But if they never have that exposure, regardless of where they grew up, they may not have this desire to go and work in a smaller rural community.”

To help recruit nurses to rural areas, the federal government in 1972 established the National Health Service Corps as part of the U.S. Department of Health and Human Services. The program provides various scholarship and student loan forgiveness options to nurses and other health care providers, so long as they work in a rural community for a set amount of time after completing their education.

Snyder said that, while those programs are helpful, they can lead to high turnover rates in rural hospitals.

“Many times, what that leads to is someone working for two years, paying off part of their loans and then leaving,” Snyder said.

Snyder acknowledged that, sometimes, providers do stay for the full five years that they are eligible to receive loan forgiveness.

According to a 2016 survey, the short-term retention rate for National Health Service Corps participants was 88%—meaning that 88% of participants chose to remain at their service site for at least one year after their required two-year term was over. And 43% of participants said that they intended to remain at their service site for five or more years.

But for nurses like Bradley, who grew up in the communities that they now care for, working in a rural hospital can mean more to them than just a job or income.

“Because our hospital is so small, and our community is fairly small, you hear all kinds of negative things. You hear some positive things, but you also hear mostly negative things about the health care system,” Bradley said. “But I know that the hospital is great. It’s filled with great, compassionate people. We can only work with what little resources we have.  I know that we are making a difference, and the way we take care of our community can make a huge difference in the long run.”

Financial realities
Rural hospitals have faced significant financial struggles over the past 10 to 15 years.

According to the North Carolina Rural Health Research Program, 170 rural hospitals have closed in the U.S. since 2005. Eleven have closed in North Carolina alone—the third-most of any state in the country.

And when hospitals were forced to cancel elective surgeries in the wake of the coronavirus, many lost one of their biggest sources of revenue—which could further reduce the number of nurses that hospitals are able to employ or put some hospitals at risk of closing.

At the request of state Department of Health and Human Services Secretary Mandy Cohen, and in conjunction with the state’s coronavirus response, North Carolina hospitals were encouraged to “suspend all elective and non-urgent procedures and surgeries,” effective March 23. Cohen defined elective and non-urgent procedures as “any procedure or surgery that, if not done within the next four weeks, would cause harm to the patient.”

Cohen permitted hospitals to resume elective procedures starting May 1.

But for rural hospitals—over half of which lose money each year, Holmes said—the effects of that initial period of cancelled procedures will be devastating.

“Those elective procedures are often the most profitable,” Holmes said. “These hospitals, which have been barely making it financially, have made a concerted effort to turn away business, reducing their revenue at a time when they need it most.”

Now, even as hospitals resume providing elective procedures, there is fear among some health care experts that even more hospitals may be forced to close their doors in the coming years due to the loss of income during the pandemic.

“There may be more hospital closures in the smaller areas because they may not be able to absorb that lack of income from the routine surgeries that are done, from the routine visits that are done, which were being put on hold,” Snyder said.

The federal Coronavirus Aid, Relief and Economic Security (CARES) Act, which was passed by Congress in March, provides some relief to rural hospitals through the Small Rural Hospital Improvement Program, or SHIP.

In North Carolina, SHIP is administered by the state Office of Rural Health and provides grants to rural hospitals with 49 beds or fewer. There are 32 hospitals across the state that qualify for SHIP funding, and in 2019, 81% of eligible hospitals received funding.

The North Carolina General Assembly also appropriated about $116.8 million for rural hospitals in its COVID-19 Recovery Act, which was unanimously passed by the House and the Senate on May 2.

Of the total $1.57 billion in relief that the bill appropriates, $65 million will be used to establish the Rural Hospitals Relief Fund, which will fund grants to “offset expenses incurred for providing patient care in North Carolina to respond to the COVID-19 pandemic.”

The state’s 20 critical access hospitals are eligible to receive the funding, as are hospitals in all tier-one counties and some tier-two counties, as defined by the North Carolina Department of Commerce.

Bradley’s hospital, which is located in a tier-one—or most economically distressed—county, will qualify for that funding. The money can be used to recover up to 60% of revenue that was lost due to cancelled elective procedures, and to provide salary support for furloughed hospital employees, among other uses.

Even as it remains unclear when her hospital will return to “normal” operations, Bradley hopes that the current spotlight on the nation’s health care system, and its downfalls, will influence future policy and funding decisions.

“We weren’t prepared for something like this because we have always been shorthanded,” Bradley said. “Even though right now we are fixing everything to the best of our ability, it’s like slapping a Band-Aid on a major bleed. You’re stopping the immediate bleed, but when you rip that Band-Aid off, it’s going to keep bleeding. Unless you fix it now, it’s going to keep seeping and it will not get better.”


Great article but that is far from a rural hospital!!
Posted on June 30, 2020

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