‘The whole system is completely stressed’: Washington’s rural hospitals grapple with ongoing staff shortage as fierce competition for workers gives big cities the advantage

Roxeanne Huddleston has worked at Newport Hospital her entire career as a nurse after her family relocated from the Seattle area nearly 20 years ago. Her experience in nursing school took her through the large hospitals in Spokane, but she knew she wanted something smaller.

“I like to get to know my patients and have good relationships with them and their families,” Huddleston said. “I want to make a difference in their lives.”

She was hired initially at Newport in long-term care and worked her way through the different departments at the hospital and clinic.

This was how it was when there was not a nursing shortage: Nurses worked their way up to more challenging parts of the hospital, adding skill sets as they progressed in their career.

COVID-19 has changed that.

Today, a nursing school graduate could get a job in an emergency department or even an intensive care unit, something that used to take years. That’s because hospitals are eager to build up their workforce after two years of a pandemic has led many nurses to look for more lucrative traveling jobs, or leave the health care profession altogether.

Huddleston said she never thought of leaving during the pandemic.

“I believe that when you work in rural nursing, you’re a part of a family, and you really do care about each other,” she said. “When someone here is sick, if an employee is sick, we reach out to them.”

But the pandemic brought a new level of intensity to the job that even veterans like Huddleston, who has been a nurse now for 17 years, hadn’t seen.

The pandemic and staffing

On the COVID ward, nurses became close to families. Huddleston recalls attending the funeral of one patient, whose partner invited hospital staff to attend. It was a reminder of the difference she and her colleagues make each day, even if it didn’t feel like it at times during the pandemic.

At Newport Hospital, the vaccine mandate led to 21 resignations. While the mandate was cited as the reason, some of the nurses were making moves to other states, retiring early or switching jobs.

This happened during the peak of the delta wave, the worst part of the pandemic for the hospital, and leaders were forced to rely on contracts to bring in more workers.

But this didn’t mean hiring agencies could always provide nurses during surges, and Newport Hospital’s leadership got creative.

Instead of hiring contracted workers, Newport hired its own temporary nursing staff. When the delta variant hit Northeast Washington, rates for traveling nurses went well over $100 an hour, said Theresa Hollinger, chief nursing officer at Newport Hospital.

When staffing agencies charge hospitals these amounts, nurses don’t get the full cut, however, and Hollinger said Newport Hospital posted a temporary position for $100 an hour to cover their night shift, where they really needed support. In essence, they cut out the middle man. And it worked.

“It’s been really successful. In fact, we’re hoping to continue that process beyond just now,” Hollinger said.

To maintain equity with full-time staff nurses, they also got double-time pay when they worked over their allotted hours.

Even as the latest COVID wave has receded, rural hospitals are struggling to fill their vacant nursing roles.

Rural hospital administrators say they still aren’t back to pre-pandemic staffing levels, which is why they voiced concerns over a proposal at the Legislature that would have required them to hire even more staff.

Rural opposition to safe staffing legislation

That proposal to impose nurse-to-patient staffing ratios on hospitals worked its way through the Washington House and Senate earlier this year before eventually stalling.

Unions representing health care workers advocated for the staffing standards as a way to keep current nurses in the workplace and help stem the tide of health care workers leaving the health sector.

The Washington State Hospital Association opposed the legislation, and several rural facilities were concerned that their challenges getting more staff would get even more difficult if the legislation passed.

One version of the bill meant that Lincoln Hospital in Davenport, Washington, would have needed to recruit at least a dozen additional nurses, said Tyson Lacy, the hospital’s CEO.

“We’re already six nurses short, and I would have needed 22 nurses total, and they don’t exist,” Lacy said.

A rural hospital recruiting more than a few nurses is a lofty goal, especially for those facilities far from any major city or urban center.

At Coulee Medical Center in Grand Coulee, there have been open nursing positions for years at a time, said Ramona Hicks, its CEO.

“I’ve found two recruiters and spent a lot of money to recruit nurses to the area and hire them, and have had zero response,” Hicks said.

Rural hospital administrators were concerned not only with the staffing ratios proposed in the bills, but with the limitations the legislation put on on-call hours for staff, which are relied upon for emergency surgeries.

At Coulee Medical Center and Forks (Washington) Community Hospital, birthing services were in jeopardy the way on-call hours were structured in the safe staffing legislation, because a surgery team must be on call during births. Other rural hospitals expected that they would have had to cut service lines or bed capacity to meet the staffing ratios in the proposed legislation.

Growing their own

Many rural hospitals are focusing on recruiting locally instead of recruiting nursing school graduates away from larger cities or competing with larger hospitals.

In Davenport, there’s a nursing assistant program based at the high school to get students interested in health care. Lacy said the students get high school credit for their nursing aid classes, and they can sit for their CNA exam following the course. He said one graduate of that course is headed to nursing school, while another is becoming an EMT.

They are trying to bring that student in nursing school back to do clinical rotations at the rural hospital. Recruiting and retaining local community members to work in health care is the strategy many leaders described.

“That’s how rural (hospitals) are going to survive,” Lacy said.

A nursing school student who has completed one clinical rotation can become a licensed nurse tech in a hospital, qualified to perform only the skills they have learned so far in school. At Newport Hospital, Hollinger is focusing on hiring nurse techs on a more frequent schedule that they make themselves to coordinate around their nursing school requirements.

The idea is that exposure will help them not only become competent in their nursing skills, but come back to work at the hospital once they complete their program.

“The hope is to grow our own nurses, to help them develop, take care of them, and help them become competent in their field so they feel good about being here,” Hollinger said.

Fixing the pipeline

Rural hospitals already have challenges with recruitment, but now, with larger hospitals offering lucrative sign-on bonuses, it has become tougher.

“If it’s hard for Providence and big systems … it’s that much worse for rural hospitals,” said Bevan Briggs, assistant professor and academic director at the Washington State University College of Nursing.

Fixing the nursing shortage requires multiple kinds of interventions and investments.

The Legislature passed some funding and proposals to help fix the nursing pipeline this session, but there are still gaps that make it challenging for nursing schools to graduate more nurses.

Nursing schools need to be able to accept more students, Briggs said. This is done by increasing the number of educators, something challenging to do when you need a master’s degree to teach and then, in some settings, take a significant pay cut.

“Faculty salaries for nursing are about what a new grad RN makes, and that’s one of the issues we’ve been trying to deal with,” Briggs said.

The Legislature has passed salary increases for some nursing instructors at community and technical colleges in the state, but not at four-year university nursing programs such as WSU.

Briggs hopes next year more can be done for nurses at the state level.

“Nurses are saying they’re burned out; and hospitals are saying resources are stretched thin; and colleges of nursing are saying, we’re trying to help out – but we don’t have what we need to help out,” Briggs said. “The whole system is completely stressed.”