The state next month may recognize Humboldt County as having a nursing shortage. Several local health officials told the Times-Standard it’s at least a start, but more will be required to solve the long-running shortage and its consequences.
“Absolutely there is a shortage in our area. It’s been going on for a long time,” Humboldt-Del Norte Medical Society president-elect and local physician Stephanie Dittmer said Friday. “It’s just been exacerbated by the closing of the nursing program at [Humboldt State University].”
Whether it is long waits for emergency room beds or fines from the state for patient care violations, the signs of the nursing shortage at local institutions are sometimes readily apparent, officials said. Local hospitals and nursing homes are relying heavily on temporary traveling nurses to fill the staffing gaps in the meantime.
“It leads to such a turnover of care that you have to re-train the nursing staff on a regular basis,” Dittmer said about traveling nurse staffing. “That just jeopardizes patient care over the long term.”
And while the potential designation of the county as a registered nursing shortage area by the California Healthcare Workforce Policy Commission in late February could open up funding to train local health care providers, reinstating a local nursing bachelor’s degree program would have the greatest effect in building the ranks of local nurses, officials said.
“That will be a single most impactful measure our community can take is to restart a nursing training program,” Dittmer said.
Efforts have already been underway for a year by Humboldt State University, College of the Redwoods and other community leaders to create a nursing bachelor’s program, with officials now eyeing fall 2019 for the inaugural semester.
Local nursing as it stands
It may come as a surprise to some that the number of registered nurses in the county was on an increasing trend between 2006 and 2016, according to the most recent data provided by the California Office of Statewide Health Planning and Development.
In 2006, the number of active registered nurses in the county was about 1,340. By 2016, it increased slightly to 1,406, with numbers fluctuating in the years between.
But 2018 will be the first year the county will be considered for a nursing shortage area designation by the California Healthcare Workforce Policy Commission, which is set to occur at the commission’s Feb. 27-28 meeting, according to the state. The designation is based on a formula that takes into account the number of days beds at local hospitals and skilled nursing homes are used as well as active nurses in the county. This year, the numbers aligned so that the county can now be considered for the designation, having fallen just short last year, according to state data.
Institutions that train primary heath care providers that are located in counties with the designation are given extra consideration as a part of a state program that provides financial support for health care training programs.
“Any designation that recognizes the shortage of local nursing staff and helps give us some tools to encourage more people to go into the field and to get more training opportunities is important not only for the nursing homes, but also the hospitals, the clinics, the hospices, to everybody,” said Rockport Healthcare Services’ CEO and geriatrician Michael Wasserman, whose company manages four of the five operating nursing homes in the county.
“It’s the entire health care continuum that is hurting by not having enough trained staff in the area.”
‘Growing your own’
Open Door Community Health Centers Director of Nursing Janis Polos said that as more local nurses near retirement age, younger nurses are needed to take their place.
After HSU ended its nursing program in 2011, Polos said the region lost its ability to generate nurses who are qualified to fill certain positions, such as those in public health that require a higher degree than a certified nursing assistant or licensed vocational nursing certification can.
Many of these nursing students who trained at local institutions were more likely to remain after their graduation, Polos said. She addedshe was a graduate of the HSU program and taught for it during its final years.
“When that program went away, the flow of people with that level of training or education went away,” she said.
In the meantime, local health care institutions have worked to make up for the loss through programs to train prospective nurses, nurse assistants and nurse practitioners, who each are able to provide different levels of care based on the level of training.
At Open Door, Polos said they have clinical rotations for nursing associate’s degree students from College of the Redwoods as well as nursing students from Chico State University and UC Davis. Polos said they also have a residency program for nurse practitioners and physician assistants looking to further their training — with Open Door and St. Joseph Hospital creating a similar program to attract physicians.
Rockport Healthcare Services conducts certified nursing assistant training at its Fortuna nursing home and the Eureka Adult School, according to Wasserman.
Southern Humboldt Community Healthcare District CEO Matt Rees said recruitment is an issue for his district.
“Being a small rural hospital, it’s hard to entice people to come to a rural area and it makes it even harder when there’s a [nurse] shortage,” he said.
Rees said there are currently numerous vacant nurse positions across several departments at Jerrold Phelps Community Hospital.
“Across the board, we need nurses and nursing assistants,” he said.
Rees said other Humboldt County hospitals with low staffing means that sometimes patients in need of further care must be sent other of the county.
“So we have to send patients to Santa Rosa and Redding and UC Davis and we wouldn’t need to if they had the nurses,” he said.
St. Joseph and Redwood Memorial Hospitals chief nursing officer Tammy Bark said the hospitals in Eureka and Fortuna are staffed with excellent nurses and that they are currently recruiting but stopped short of saying there is a nurse shortage at the facilities.
“We’re always trying to recruit. We backfill with travelers when needed,” she said.
Bark didn’t detail any recruitment-specific programs but said they offer current nurse staff advanced training, a new nurse residency program and fellowships that help nurses train for specialty positions in surgical, labor and delivery, critical care and other departments.
“When you have a program like that it attracts applicants to your hospital,” she said.
Bark said traveling nurses takes burden off staff.
“We always staff to Title 22 ratios,” she said referencing regulations that require for a certain number of nurses for a certain number of patients.
The ratio depends on the department and varies from 1 nurse per five patient up to one nurse per patient, Bark said.
In November, the California Nurses Association filed a work-to-rule notice asking for St. Joseph nurses in certain departments not be forced to work long, mandatory overtime shifts and to have at least 10 hours off between shifts. The next month California Department of Public Health personnel came to St. Joseph Hospital to investigate staffing levels.
“I do not believe those particular problems are a result of a shortage of nurses,” St. Joseph charge nurse and California Nursing Association chief nurse representative Lesley Ester said.
“The problem is retention.”
Ester said CR produces around 40 to 50 registered nurses every year. In the past several years, St. Joseph has lost more than 60 nurses in one unit alone. She said other hospitals such as the one in Santa Rosa pays nurses $13 and hour more than at St. Joseph. Ester said St. Joseph nurses will continue the work-to-rule notice and that one may be forthcoming at Redwood Memorial Hospital.
“They would also like 10 hour breaks between shifts and we support them,” she said.
Mad River Hospital chief nursing officer Sarah Isaacson painted an idyllic picture of working in a community hospital rather than ones owned by large corporations.
“What Mad River does is we offer what a community hospitals can offer and that big corporations can’t,” she said before listing numerous staff benefits.
Isaacson said the hospital uses “float nurses” as one way to alleviate pressure on staff.
“We also give our staff float registry — float nurses that give them breaks and support them and a lot of other hospitals can’t do that,” she said.
Isaacson said that is difficult for some larger hospitals to pull off because of how many float nurses that would take. She also said the hospital has a high number of nurses that have been there for a long time.
“So by having so many long-term nurses, it gives the stability,” Isaacson said.
But Polos said attracting younger licensed nurses has been an ongoing problem.
Compared with urban and metropolitan areas, nursing positions in rural areas generally pay less, Polos said. While Humboldt County has many unique and attractive characteristics that fit certain lifestyles, Polos said younger nurses might be more attracted to cities based on the lifestyle and the resources that are available there.
Then there are spouses to consider.
“Your spouse needs to have living satisfaction and job satisfaction here as well,” Polos said. “That is a big deal about maintaining a workforce here, not just in nursing or medicine.”
Polos said that they attend job fairs to work to promote the advantages of becoming a rural community health provider in Humboldt County, but said that only goes so far.
“I can’t think of anything special that we’re doing for nursing except for increasing our visibility,” she said.
While she said a bachelor’s degree nursing program alone won’t solve all the issues of attracting local providers, Polos said it will be a significant improvement.
“There is success in growing your own,” Polos said.
A lack of nurses places a burden on the entire local health care system, officials said, and can result in risks to patients.
Dittmer, who is the Fortuna Open Door clinic’s medical director and Redwood Memorial Hospital hospitalist director, said that a lack of nursing staff at a hospital setting leads to a direct inability to admit people into the hospital even if the rooms are empty.
Dittmer said there are times when the hospital is “closed,” meaning it can’t admit new patients because of lack of staffing. Other times patients have to be flown out of the county because there are not enough beds available for local treatment, she said.
“You can have a really nice new building and new tower and have the room available to put a patient in, but unless there is a nurse to take care of that patient, that room cannot be filled,” Dittmer said. “That patient may be in the emergency room and may need to come up to the floor, but because there is no nurse to be assigned that means the patient will have to wait in the emergency room.”
A lack of nursing home nurses also has the ability to impact hospital beds, Dittmer said. Dittmer said there are sometimes situations where nursing homes don’t have qualified nurses to administer certain IV antibiotics for example, and the person will have to remain in the hospital for long-term treatment. If there are not enough nurses to staff nursing home beds, Dittmer said the same outcome can apply.
“It’s an intricate web of interdependence,” she said.
Locals hospitals and nursing homes rely on out-of-area traveling nurses to fill staffing gaps, which Dittmer said require physicians to use more time for training. Dittmer said traveling nurses may not be as invested in the community as a local nurse, though she said there are individuals who have proven otherwise.
After coming under new leadership last year, Rockport Healthcare Services has been working to improve patient care and trust in Humboldt County following public outcry over patient care, including allegations of wrongful deaths as part of ongoing lawsuits. Rockport previously attributed its plans to close three Eureka nursing homes in 2016 — but ended up closing one last year — because of millions in financial losses caused by having to hire temporary nurses to fill staffing gaps.
Suzi Fregeau, a senior care ombudsman for Area 1 Agency on Aging in Eureka, has been vocal in past years about her criticism of the quality of care at Rockport’s nursing homes, but said the change in management has shown marked improvement in the past few months even though she said more nursing staff is still needed.
“The staff are happier. They only have two traveler nurses. The staff is stable. The staff is happy. The residents are happy,” Fregeau said of one nursing home she recently visited. “… I want the community to know that things are getting better. They are not perfect. I don’t think they ever will be in a nursing home.”
Wasserman said their nursing homes still rely on many traveling nurses, but said the ideal situation to fulfill their company’s vision for patient care is to have “homegrown local staff.”
“There is no one that cares about your community more than the people who live there,” Wasserman said. “We feel very strongly that our nursing homes need to be an integral part of the community.”
A new nursing school?
California Center for Rural Police Director Connie Stewart also works in the office of HSU President Lisa Rossbacher and was tasked with building a metaphorical bridge between the registered nursing program at CR to a bachelor’s degree in nursing program at HSU.
“We’re hoping to have curriculum by February,” she said.
That curriculum plan for the HSU nursing program would need to be approved both by HSU and California State University administration, Stewart said.
“We’re shooting for fall ‘19,” she said about when registered nurses from CR could start attending HSU.
But there’s still work to do in the meantime.
“There’s a large fundraising program,” Stewart said.
Bark said she thinks bringing back a bachelor’s nursing program to Humboldt County is a good idea.
“I think that we absolutely support access locally to advanced education for nurses,” she said.
“We do have many staff from the CR program. I support that and I think that would be a real benefit.”
Ester and Rees were also enthusiastic about the idea of this program.
“I’m very excited to hear about the collaboration,” she said.
“I think it will help,” Rees said. “We need nurses as well as anybody in the county, even more so.”
Will Houston can be reached at 707-441-0504 and Hunter Cresswell can be reached at 707-441-0506.