July 31, 2019 — “I love the fact that when my patients come in sick, they leave with a smile on their face and say, ‘Thank you,’” said PeaceHealth Peace Harbor nurse Emily Davidson.
She decided to become a nurse after her grandmother had a stroke and was taken to Peace Harbor’s emergency department.
“They actually didn’t have any beds on the floor available, they were all full,” she said. “We didn’t want her transferred to RiverBend. So they gave the option of an OB room because there weren’t any babies being born at that time. So she was taken care of there for a couple of days and just received the most amazing care. That’s why I wanted to become a nurse: the one-on-one care, getting to know your patient, not only your patient but your family members. It really made a difference for me and a life change. So that’s why I wanted to work here and stay here.”
According to Davidson, PeaceHealth helped her with scholarships to become a nurse, which she admitted is not a job for everyone.
“You have to love it,” she said. “You don’t do it because it’s a job. It’s a career that you have to love. If you love it, then you’ll do it. Most of the seasoned nurses I know, they all tell me how much they love it. And you hear of people in this career for 20 years or longer. With only two years of experience, I’m seeing why they love it. You don’t see that in other places, so for me, that’s rewarding.”
But keeping nurses like Davidson in Florence can be a challenge. From housing issues to overall provider and nursing shortages in the industry, staffing rural hospitals can be a challenge. This was of particular concern a few years ago, as Peace Harbor’s wait times stretched into hours, and sometimes days. Since then, the hospital has worked on creating more positions, increasing employee benefits and nurturing innovation in the system.
“The way we see it now, I think we’re close to the positions that we need to fill,” Peace Harbor Chief Administrative Officer Jason Hawkins said. “If we can keep them filled, we’re in better shape than we have been in a long time. I can’t speak to years and years gone by, but speaking to the other nurses in times gone by, they’ve commented that it’s getting better.”
Peace Harbor’s struggles with employee retention became public debate in 2016 and 2017, when several care providers and one general surgeon left the community at the same time, followed by a protracted contract negotiation between the Oregon Nurses Association and PeaceHealth.
“I would say that it was kind of a baseline model that didn’t have a lot of redundancy built in,” Hawkins said.
The issue was not that the medical center did not have positions filled, but that they did not have enough positions to cover sudden staff shortages, such as someone calling in sick, taking a leave of absence or moving to another city. The hospital was constantly trying to cover for these normal shortages.
“There’s enough turnover in healthcare that we want to build in redundancy that will take care of these issues 99 percent of the time,” Hawkins said. “Ideally, 100 percent of the time, but there are always those situations and circumstances that we are challenged with. It could be a flu epidemic that could affect our employees. Our rules are that if you were to get the flu, they’re not supposed to come to work until they’re fever free for 24 hours. But if the flu hits five or six nurses in a unit?” It can cripple the unit. “You get to a tipping point, based on the staffing problems, where everything is lined up and it’s going to become unsafe. … I think Peace Health understands patient safety is important. So once we shared some of that narrative with leadership, it’s not been a difficult process to get the improved.”
In the past few years, Peace Harbor has doubled its labor and increased staffing models. It has added a clinical educator position who keeps staff trained and up-to-date, doubled labor and delivery staffing and recently made a full-time charge nurse position in the emergency department.
“I would also say that adding the charge nurse position in our ER around the clock is providing more resources for our patients and our other nurses to rely on to help elevate some clinical decision making that needs to be made,” Hawkins said. “It frees them up to do more direct patient care. The charge nurse can help arrange for transfers, help to make sure we’re getting results back from our labs, radiology and critical patients.”
Hawkins also stated that the hospital has been working on competitive benefits and wages, along with newer equipment for staff — “Like a Nexus unit for medication dispensing is more effective and allows them to spend more time with the patient instead of gathering meds. We have just deployed nine new airflow beds to help pressure increase. And our team is getting a new patient monitoring system in January or February. And the reason I say that is, when you’re trying to get a model in place to recruit and retain, you want to be able to have competitive wages and benefits. You want to be able to get them a decent work environment, have good staffing plans where they feel safe and they can take care of their patients, and not ask them to work too much overtime because they have families that need to be taken care of.”
Peace Harbor has also worked on decreasing readmissions through programs such as Mobile Integrated Healthcare (MIH) and Home Healthcare.
Robin Allen, director of clinical services, said, “I think the communication with the MIH provider is that they work really closely with home health, so the patients that are being discharged don’t fall between the cracks. They make sure that MIH gets out there to make that connection, then follow up with home health. It’s a really great system. They’re great partners.”
The changes have ultimately helped bring down patient wait times.
“I think what you’re seeing is our ‘left without being seen’ rates in the ER are going down,” Hawkins said. “Patients that are coming and having to wait are finding they can stay and be seen in around 15-20 minutes. We don’t get it right all the time, but we are getting better at it. I’m also seeing us providing better care when they’re here. Our readmission rates are declining as well. Our length of care in acute care is declining in certain diagnosis. We’re getting meds to them faster the first half day. We’re taking care of them and they’re being discharged and getting them home sooner. And they’re not bouncing back. We’re not pushing them out the door too quick. So we’re seeing those readmission rates go down too.”
But there are still occasional issues. As the hospital works promote within to fill newly created positions, an occasion “perfect storm” can occur that leaves staff short.
“We still have challenges with that,” Hawkins said. “We’re still working where those baseline models are still fragile.”
One example is a recent shortage in Peace Harbor’s Intensive Care Unit (ICU), which has led to some patients being transferred to other facilities.
“Normally we have a census of 2 to 3 patients in our ICU,” Hawkins said, with the possibility of up to four patients at any given time.
However, two of the charge nurses on the regular medical floor were promoted, which the hospital believed they could cover. Then the unexpected resignation of one nurse, followed by another who had to take leave for personal reasons, left the hospital short on staff in the Medical-Surgical unit. To cover that unit, they had to look at other units they could temporarily cut back on until new nurses were hired. They turned to the ICU, cutting back on the census of patients that would be allowed. Instead of having up to four patients, they limited it to just one patient at a time.
“We couldn’t guarantee that we would have two RNs in there 24/7,” Hawkins explained. “We definitely felt comfortable we could have one. Rather than put any of our patients in jeopardy with not enough staff, we’re limiting our census.”
But by limiting the ICU to just one patient, Peace Harbor had to transfer additional patients to other facilities, such as RiverBend. This is being done by the Western Lane Ambulance District, which in turn has to approve overtime for its ambulance staff to be able to make the transfers.
“We’ve moved people about half a dozen times,” Hawkins said, pointing out that transferring people from a 21-bed facility is not entirely uncommon. “In my time here, we’ve bumped up at that ceiling maybe one time, usually flu season. But then, the entire region was full. Sometimes you can’t find a bed anywhere.”
The ICU shortage at Peace Harbor is not the norm and is expected to be alleviated within the next few weeks.
“It takes us two to four weeks to bring in a traveler,” Hawkins said, referring to nurses who travel to different cities to fill in positions that are temporarily vacant. “They have to do background checks, get a license sometimes. And get acclimated through our systems. It’s really unfair to our patients to kind of drop in a nurse who doesn’t know our processes and protocols. That’s unsafe too. … It happens across the industry. You might find a 500-bed hospital that may say they’re full. But when you look at it, a particular unit may be closed down entirely because there’s just not enough staff. We don’t particularly do that here. It’s happened a couple of times, you get close, and then you get covered. We try and get travelers from other parts of the Oregon network. Unfortunately, we had to make this decision in this case.”
As for hiring a more permanent employee, the process can take longer, anywhere from four to 12 weeks.
“That’s just the reality of it,” Hawkins said. “Our turnover is a little less than the state average. People who come here really want to be here, and that’s a really neat thing.”
But finding people can be difficult. First, there is a national shortage of healthcare workers, both in providers and nurses.
“I think we’ve been able to influence a lot of those things, with the exception of workforce housing. That, I think, is important to share,” Hawkins said. “Florence is a beautiful place. As a caregiver, you want to work either urban or rural. And then you make that decision, and decide where you want to work that’s a smaller community. I think Florence is a great solution for that, and I believe in that. But the housing component for rural communities is pretty challenging. We’re always, as a team, trying to find housing for new caregivers and there’s some great stories. Recently, one of our caregivers helped out another caregiver and their family who was recently hired.”
Allen explained, “They were living in a hotel for two weeks. We were able to find them a place to live, but it was very difficult for them to, on their own, find a place.”
Another problem is the overall lack of employment in the area. While a nurse can be employed at the hospital, their spouse may have difficulty finding steady work.
“Sometimes in rural areas, it’s the spouse. One spouse is a nurse, the other is a school teacher. That might work out nice. We’ve had people apply where the spouse in an electrical engineer, or a marine biologist. Some of those jobs are nearby, but not right here. Sometimes those are challenges for us,” Hawkins said. “It’s an imperfect system that we’re trying to make the best of. I think if a healthcare worker wants to work somewhere rural in a great community, I think Florence is a great spot. I really do.”
Davidson pointed out that the benefits of working as a nurse in a rural area can outweigh those in working in a metropolitan area.
“I feel like the one-on-one patient care really helps because you get to know your patient better than most hospitals. With bigger hospitals, I always hear seasoned nurses say that it’s hard to get the one-on-one patient care that they see here. And that keeps a lot of nurses here, the chance to get to know your patients better. I couldn’t imagine being busy, busy, busy and not having the chance to really sit down and say, ‘How are you?’ and get to know not only what’s going on in the hospital, but what’s going on outside of the hospital.
“I feel like that’s a good reason why nurses want to stay here. I feel the more nurses we have come in, the more nurses we’ll have stay and the staffing issue won’t be in existence.”
By mid-August, Hawkins expects the Medical Surgical Unit to be fully staffed again and the ICU can go back to normal levels, though those levels are expected to change as the community grows.
“We’re a reflection of the community,” Hawkins said. “As the community needs change, I think that as more Baby Boomers come in who will need services, our need for primary care providers and our need for additional lab and radiology will increase, and we’ll continue to grow. And we’ll keep an eye on that. It’s a gradual growth.”