Wednesday 23 March 2022

Travel Nursing, Nursing Responsibilities, Nursing Professionals, Nursing Career, Nursing News, Nursing Exam US

It’s no secret that there has been a disparity in agency nurse and staff nurse wages over the past year and a half. And the disparity is becoming increasingly bigger as the weeks pass by. Travel nurse pay has never been higher since the pandemic started, with August numbers showing a weekly average rate of over $2.5K, compared to a December 2019 average weekly pay of just over $1K. And as staffing issues continue to plague the entire country, they show no signs of slowing down.

However, in an attempt to stop the ballooning wages—and perhaps better balance the gap between staff and travel nurse pay—some states have introduced legislation to cap agency nurse pay. As you can imagine, the idea has a lot of people talking, so here’s more on what the legislation is proposing, and how nurses are responding. 

State and Federal Moves

During the pandemic, there have been both state and federal moves towards enacting legislation specifically aimed towards more regulation for staffing agencies and limiting travel nurse pay rates. Most recently, the American Health Care Association/National Center for Assisted Living, LeadingAge and a coalition of long-term care and senior living organizations sent a letter to White House officials warning against the “price gouging” happening in staffing agencies and how the practice is harmful to both patients and providers, who receive fixed reimbursement primarily through Medicare and Medicaid. 

That letter was followed by another one, signed by 200 supporters, urging Congress to enlist federal agencies with competition and consumer protection authority to investigate the conduct of nurse staffing agencies to determine if it is the product of anticompetitive activity and/or violates consumer protection laws. The letter cited that nursing staffing agencies are sometimes taking as much as 40% of the fee collected from hospitals, adding that continuing to pay the high fees to staffing agencies is “ simply unsustainable.”

Supporters behind the movement to cap travel nurses’ pay say that the pandemic has thrust the need for more requirements for staffing agencies into a major spotlight and that ignoring the financial and regulatory issues brought on could lead to long-term impacts. 

Nationally, the American Health Care Association (AHCA) sent a letter to the Federal Trade Commission (FTC), urging the FTC to use its authority to protect consumers from anti-competitive and unfair practices regarding agency staffing. Statewide, Massachusetts and Minnesota are the only two states to already have agency wage caps in place, but some states did make initial moves to address high wages during the pandemic. (Although, notably, Massachusetts raised its caps by 35% for the amount agency staff for nursing homes could be paid during the pandemic.) In Minnesota, wages were also raised, but only slightly: agency RNs can make a max of $58.08/hour at regular pay and up to $99.90/hour for holiday pay. 

Other states have tried to make some kind of moves towards regulating staffing agencies. For instance, with the advent of the pandemic, Connecticut prohibited profiteering during emergencies, with violators subject to fines by the state Department of Consumer Protection and the Office of the Attorney General. The New York State Health Care Facilities Association has also tried to introduce legislation but has not been successful yet. So far, Pennsylvania is the only state that appears to have the most concrete plan in place for moving forward with legislation specifically aimed at regulating staffing agencies. 

What the Legislation Says 

Although the legislation in Pennsylvania hasn’t been formally introduced yet, Pennsylvania Representative Timothy R. Bonner wrote a memorandum on November 5, 2021, that he plans to introduce Pennsylvania Health Care Association (PHCA)-supported legislation that will “require Contract Health Care Service Agencies who provide temporary employment in nursing homes, assisted living residences and personal care homes to register with the Department of Human Services (DHS) as a condition of their operations in Pennsylvania.”

As part of the requirements, the proposed legislation would establish maximum rates on agency health care personnel. Bonner noted that nursing homes in Pennsylvania lost 18% of their workforce, with 68% of the state’s facilities struggling to meet minimum staffing requirements. As a result—like many other healthcare facilities in the nation—agency staff filled those needs. However, in his memo, Bonner cited a statistic that 39% of the surveyed facilities said that they would not be able to afford to keep their facilities open for more than one year. 

Part of that, he added, was the added cost of paying staffing agencies. In some cases, wages have ballooned to over 400% above the median wage rate for long-term care facility staff. Additionally, some of the facilities themselves have lost their own staff to travel agencies. And because long-term care facilities are funded primarily through Medicare (70% of all care in the state’s facilities are through the Medicare program), paying high agency staff wages has significantly drained Medicare funds as well.  

Although the legislation would incorporate a cap on agency pay, it also aims to allow state agencies oversight of supplemental health care service agencies, which they currently do not have. That would include everything from registration requirements to an established system for reporting and penalties. 

“Recognizing the increased role that these agencies play in the day-to-day operations of nearly 700 nursing homes and 1200 assisted living residences and personal care homes, we must ensure they are operating in a manner that supports the long-term care sector and high-quality resident care,” Bonner wrote. 

What Nurses Think

As you can imagine, travel nurses have something to say about this legislation. In a travel nursing group on Facebook, over 270 comments poured in during a discussion on travel nurse wage caps. 

Some nurses hinted that they would strike if legislation capping pay came to pass, while others warned that there would be no need for a formal strike--travel nurses could simply not pick up new assignments, making staffing shortages even worse. 

“I have just had my best year ever. I could easily sit out for 6 months or change careers,” wrote one nurse. “They do not want to screw around with nurses right now. It is curious that people making legal policy don't possess the professional credentials to do our jobs but believe that they know better than us anyway,” this nurse added. 

Other nurses pointed out that a wage cap could potentially put both patients and healthcare facilities at risk amidst another COVID-19 surge or even another health emergency. “If they try to cap RN pay, what will happen if there’s another COVID surge,” commented another nurse. “Let’s say they cap our rate at 5K, if there’s another surge they will most likely not get much RN’s wanting to help. So they better tread lightly otherwise they will have bigger problems in their hands. A severe nursing shortage.” 

Another commenter chimed in to agree with Celne: “Right?” wrote a nurse. “If they cap, why would anyone want to go help with surges. I’m not going into a hot mess doing more work when I can stay capped right where I am for less work.” 

There is also a petition circulating online as a result of the letter to Congress that aims to stop the efforts to cap travel nurses pay. “We all know that wage caps are going to have a detrimental effect on staffing, forcing even more nurses to give up working at the bedside and further worsening the problem at hand,” the petition reads. “What about encouraging legislation to protect the safety and rights of nurses? What about legislation to nationalize safe nurse-to-patient ratios? What about legislation to set a fair, competitive minimum pay for nursing? Reach out to your elected officials and voice your concerns. There are many solutions out there, but this isn't one of them.”  

It’s left to be determined exactly if the legislation will pass and what the possible ramifications could be for both the travel nursing industry as well as the ongoing nursing shortage.


Saturday 19 March 2022

COVID-19, Nursing Responsibilities, Nursing Professionals, Nursing Skill, Nursing Exam US, Nursing Degree, Nursing Degree US

In a major move that signals just how far we have come in the COVID-19 pandemic, the Centers for Disease Control and Prevention (CDC) announced drastic changes to its facial mask recommendations for a majority of the country on Friday.

Using data available from hospitals and public health departments, the CDC announced that nearly 70% of the country is considered “low-risk” for COVID-19 transmission which means they can ditch wearing a mask in indoor settings.

What the New Guidelines Mean

The new guidelines use the CDC’s COVID-19 Community Levels (you can check your community’s risk in the link) to determine their recommendation for using a mask indoors. They also use data that assesses how many hospitalizations are in the area along with available hospital beds to determine risk. Under the new guidelines, the hospitalizations and available beds are utilized more than the rate of new infections.

The risk levels go by color:

◉ Green = low risk. People in areas with a low risk are advised to wear a mask as they feel comfortable, based on their own personal preference.

◉ Yellow = medium risk. People who are immunocompromised or at high risk for getting severely sick are advised to wear a mask indoors.

◉ Orange = high risk. The CDC recommends that all people, regardless of vaccination status or personal risk, wear a well-fitting mask indoors. This includes K-12 schools and other community settings. 

The CDC also recommends that certain people and in certain situations, mask-wearing should continue. For instance, anyone with disabilities, anyone traveling, and anyone who is sick or caring for people with COVID-19 should continue to wear masks indoors. Additionally, the CDC continues to recommend masks on public transportation. However, the CDC does not require masks be worn on either private or public school buses, although schools may elect to put mask mandates into place. 

Why the Change?

The change has happened in response to a few different factors: rates of both new COVID cases and hospitalizations have plummeted in the last few weeks and a large majority of Americans are vaccinated, boosted, and yes, previously infected. Additionally, health leaders have agreed that the way we need to treat the pandemic has shifted as well.

Earlier in February, Dr. Fauci explained that COVID will never be eradicated, and even while the “full-blown pandemic phase” of the virus comes to an end, the virus will most likely live on as an endemic. In other words, COVID is here to stay and we need to learn to live with it.

Part of how we learn to live with it involves taking things like mask-wearing to the local level, based on both personal risk (for people who may be immunocompromised, for instance) and community transmission, as well as available hospital resources.

"We want to give people a break from things like mask-wearing," CDC director Rochelle Walensky explained at a news briefing announcing the shift. 

But the agency also explained that basing mask recommendations on community risk and hospital strain allows for changes as needed. In other words, if COVID transmission picks up again—or hospitals become strained under a surge—your area could shift from low-risk to high-risk, meaning masks may be recommended once again. 

“As the virus continues to circulate in our communities, we must focus our metrics beyond just cases in the community and direct our efforts toward protecting people at high risk for severe illness and preventing COVID-19 from overwhelming our hospitals and our health care system," Walensky added. 

Leading nursing organizations like the American Nursing Association (ANA) have yet to respond to the updated mask guidelines. On social media, people have expressed confusion over how a decrease in masking could affect high-risk individuals who may have even less protection if others around them aren’t masking, as well as children who are too young to be vaccinated.

“I appreciate the push to take us back to some modicum of normalcy, I just wish it was not until all people who can be vaccinated are (little kids for example) and national mortality rates fall within one standard deviation of the pre-Covid average,” commented Sarah Kahn on Facebook.

What About Healthcare Professionals?

So if mask mandates are being dropped left and right across the country, does that mean that nurses don’t have to wear masks anymore?

Not exactly. The CDC is clear on this one: the new guidelines do not apply to healthcare workers. The CDC’s website states: “CDC’s new COVID-19 Community Levels recommendations do not apply in healthcare settings, such as hospitals and nursing homes. Instead, healthcare settings should continue to use community transmission rates and continue to follow CDC’s infection prevention and control recommendations for healthcare settings.” 

Considering the fact that hospitals and healthcare settings contain both a potential for high transmission and immunocompromised individuals who could become severely ill if infected, it’s expected that universal masking for healthcare workers is here to stay. Additionally, nurses and healthcare professionals can expect to be required to wear an N95 when caring for patients with active COVID-19 infections.

Masks may be here to stay, but as nurses, we can look at the bright side: it will make dealing with unpleasant smells a whole lot easier, right?


Wednesday 16 March 2022

Violence against healthcare workers, especially nurses, is not a new conversation. In fact, the conversation has recently been highlighted as over the course of the last three years there have been an increasing number of attacks on nurses. Isolation, ever-changing mask, and quarantine rules have made healthcare workers prime punching bags for the frustration that patients have felt, especially since the start of the pandemic in March 2020.

Violence against nurses is the true epidemic

Most recently at Ochsner Health System located in New Orleans, Louisiana, an ICU nurse was attacked and knocked unconscious inside a hospital. The nurse suffered a broken jaw and broken teeth that required surgery, according to authorities. A nurse was attacked by a patient visiting a family member. Specific details surrounding the attack still remain unknown but thankfully after a $12,500 reward, $10,000 from the hospital, was offered as well as extensive media coverage, the suspect was arrested and charged for the brutal attack.

"Workplace violence in any form — physical, verbal, non-verbal or emotional — is unacceptable, and we will not tolerate this behavior," Ochsner President and CEO Warner Thomas said in a statement released by the hospital.

Louisiana Takes Action

While the assault on anyone is a crime in all 50 states, for some reason assaults against nurses and healthcare providers seem to go either unreported, unfounded, or the attacker is not caught. In the case of the ICU nurse at Ochsner, assault charges were filed; however, this is not always the case. 

Despite the arrest, this assault should never have taken place and Oschner as well as the state of Louisiana are doing everything in their power to stop violence against healthcare workers. Oschner’s CEO is personally invested stating, “workplace violence against healthcare workers has been escalating throughout the pandemic and has reached a point that legislation needs to be considered to make this violence a felony. This consideration under review by a Louisiana task force comes as U.S. hospitals grapple with an increase in disruptive or violent incidents in hospitals — many involving hostile visitors – adding further stress to the healthcare workplace.”

The Healthcare Workplace Violence Tasks Force in Louisiana led by Ahnyel Jones-Burkes, DNP, is helping to make changes to the conversation regarding violence against healthcare workers. 

“No one should be afraid to go to work especially when they’re providing care for patients, especially in a pandemic setting,” said Jones-Burkes.

As a result of the uptick in recent attacks, the task force which includes not only healthcare professionals but also law enforcement representatives approved recommendations for the Louisiana Department of Health.

One of the recommendations is that healthcare settings post signs warning that abuse or assault of health workers is a serious crime.

An additional recommendation requires health care systems to report violent acts against their staff that occur on their property within 24 hours to the appropriate authorities.

“My personal philosophy would be that all of these need to be reported within 24 hours,” said Karen Lyon, Ph.D., a member of the task force.

Jones-Burkes said, “We settled on 24 hours, so that was a big step for us because right now the way it’s set up a victim has to report and after you’ve been assaulted, or something has happened maybe that’s not the first thing that you are thinking that you are going to do.

While these actions may seem small, they are a step in the right direction. It provides guidance to healthcare systems as well as staff. Furthermore, it gives reassurance to staff members that all assaults will be taken seriously and appropriately reported. 

Underreporting, which is the cause of most violent assaults, is a common occurrence for fear of retaliation. Most assaults are not reported to the authorities or even the hospital management. 

White House Support, Stalled by the Senate

In spring 2021, the U.S. House of Representatives passed the Workplace Violence Prevention for Health Care and Social Service Workers Act (H.R. 1195). The bill, which passed the House with full bipartisan support, would require healthcare and social service providers to develop workplace violence prevention plans. Furthermore, all employers would have to provide additional training to staff members and submit annual reports of violent incidents to the U.S. Department of Labor.

The White House said it supports the bill. Unfortunately, the bill has yet to be voted on by the Senate. 

This bill, while not going to stop all violence, is a HUGE step in the right direction. It provides clarity regarding the measures that need to be taken to help prevent healthcare workplace violence. However, until it is passed by the Senate the aforementioned prevention plans, training, and annual reports will not occur. It is crucial that the Senate vote on the bill but at this time there is no clear date for discussion.


Tuesday 15 March 2022

Travel Nursing, Nursing Responsibilities, Nursing Career, Nursing Professionals, Nursing Degree, Nursing Degree US

There have been many days after working a twelve-hour shift that I have left feeling like a failure.

And to be quite frank, it has nothing to do with my own ability or actions, but it is often a result of a systemic failure of unsafe staffing on not only the unit but for the entire hospital. I have worked so many shifts prioritizing and juggling a to-do list longer than a mother-of-four’s grocery list. The physical and emotional fatigue of constantly living in sympathetic response slowly breaks nurses down. 

It is a horrible feeling to realize that a patient had to sit in their wet briefs, had to wait hours for pain medications or even started to decompensate without anyone noticing because I had been stuck in a room of an actively dying patient. In those moments how do I choose where to be and which patient needs me more? Ultimately, I shouldn’t have to, there should be someone to help with my other patients but there isn’t. Our country has been dealing with safe staffing issues for decades, and the pandemic has only exacerbated an already detrimental problem. 

After spending 5 years as a travel nurse and experiencing hospitals in 11 different states, I am personally familiar with the large discrepancies within the staffing ratios across our country. Depending on the hospital’s normal ratios, the role can feel like two completely different jobs entirely. I have worked in Emergency Departments where I was responsible for 9 different patients at a time, but I have also worked in hospitals where I have only had to care for a max of 3 patients at any given time. That means that just based on hospital location and management, I essentially have had to work the role of three nurses. 

One of the most shocking details of this scenario that onlookers from outside the medical field do not realize is that even though nurses in the states with higher ratios essentially do the work of three nurses, they oftentimes get paid even less than the hospitals with smaller ratios. As a general rule, the west coast far surpasses the east coast in terms of safe staffing as well as pay. With a higher concentration of nursing unions (specifically California) and legislation that supports safe staffing, the west coast, as a generic blanket statement, provides some of the most ideal working conditions in terms of staffing ratios. Although nursing wages fluctuate nationally based on the cost of living, it remains mind-blowing that our country will not implement national standards for staffing demands. 

I will never forget the moment when I became so overwhelmed with my patient load, that I just stood in the hallway, gazed at all of my rooms as the list of tasks I needed to complete scrolled through my head like the beginning of Star Wars. At that moment I thought to myself, “who is going to die first; because I certainly can’t keep all of them alive right now by myself.” 

It was a November day and I was working a mid-shift, and the day started out like many of them did at that hospital. Chaotic. This was my very first travel assignment and I felt unsure of myself in so many ways, and insecure about what “normal” was. I didn’t want to complain, because maybe this is how all hospitals in the country function, and my first job was some diamond in the rough that only had a 4:1 ratio instead of a 7:1. 

I was responsible for four rooms and three hall beds. My first sick patient to arrive was morbidly obese, experiencing massive cardiac problems, and we had to call anesthesia to intubate him due to his large habitus. I was giving cardiac meds I had never hung before through a single 22G IV in his chest, and the physicians wouldn’t take the time to put a central line in him in the ED, because they wanted to let the ICU residents do it. Unfortunately, I couldn’t advocate for them to place one in the ED.

Approximately 30 minutes after his arrival, they put an elderly lady experiencing a stroke next door. We ended up hanging TPA which normally would have required a nurse to stay with her for at least the first hour, but we didn’t have any additional staff to come help. So, in between all of my NIH’s, I would peek in next door, secure the soft restraints a bit tighter and crank the sedation as high as I could, and just pray that both of them were stable enough to safely make it upstairs when the time would allow.  

But, then I got a call about 45 min after her arrival from the charge that said “Hi, sorry but you have the last available room. I’m sending you an LVAD patient in V-Tach to your last room.” 

This was the moment. 

This is when I looked down the hall and wondered which patient’s care would be so horribly mismanaged that I might unintentionally kill someone. Not only did I have three patients that a lot of hospitals would dedicate one nurse to each of them, but I also had the additional four patients that I hadn’t even looked at in hours. 

Unfortunately, this enormously unsafe scenario is not a rare scenario, especially given the current events over the last several years and nurses leaving the bedside at an unprecedented rate. ICU nurses have been forced to often double and triple their normal patient load, and floor nurses have been asked to do dramatically more work for more patients with even less payout and resources. 

The saying “safe staffing saves lives” not only applies to patient lives but also directly relates to helping preserve as many nurses at the bedside as possible. Thankfully crisis travelers and additional government funds have helped decrease the load on many hospitals, but they are only a temporary fix that allows the staff to come up for a few gasps of air, but as soon as they leave, the staff returns to their drowning. Staffing issues will continue to be one of the most concerning problems in the field of nursing for years to come, and I can only hope and pray that my fellow nurses will find relief quickly. 




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