When patients enter a hospital, there’s a range of health care professionals involved in their care — but “really, they’re here for the nursing care,” said Cassie Lewis, chief nursing and quality officer for Bon Secours in Hampton Roads. 

They’re the ones who closely monitor patients and most commonly appear at their bedside. “Nobody is better positioned to see changes in clinical conditions of our patients than the nurse,” Lewis said. “And so without nurses, we're really in a world of hurt because we've lost that connection to the patient.”

Bon Secours is one of many health systems throughout the region and Virginia that are dealing with an ongoing shortage of nurses. 

That’s in line with national trends across the industry and is linked to a mix of rising workplace violence, complications in nursing education and burnout that worsened during the pandemic. 

The Commonwealth had among the country’s lowest ratios of registered nurses to patients — 10.5 RNs per 1,000 people — as of last year, according to the Virginia Department of Health. 

In response, local officials are ramping up efforts to recruit and retain nurses — while also rethinking how to best deliver care with fewer people.

A convergence of issues during the pandemic 

Even before the pandemic, health systems across Virginia faced shortages of health care professionals. 

But the COVID-19 crisis greatly magnified things, said Julian Walker, vice president of communications with the Virginia Hospital & Healthcare Association. For one thing, hospitals struggled financially. 

Overall hospital volumes went down, including emergency room visits, in-patient admissions and non-emergency procedures – which are a big revenue driver for hospitals, he said.

At the same time, there was increased competition for travel nurses and difficulty sourcing needed materials like personal protective equipment because of supply chain issues. 

“It was really sort of burning the candle at both ends,” Walker said.

Lewis, who works at Bon Secours Harbour View in Suffolk, said like everywhere else, “COVID definitely put us in a significant hole with nurses.”

Some nurses near retirement opted to leave early during the stressful time. Others wanted to stay home to protect vulnerable family members, or simply got too burned out.

At the peak of the pandemic, Bon Secours Hampton Roads had a nurse vacancy rate of at least 30%. It’s now at about 12%, which is still high, Lewis said.

She said the region is already uniquely challenged by military relocations that can cause high turnover of nurses.

Then there was an unexpected rise in aggressive and demanding patients, with serious consequences. 

“Coming out of COVID — and I would love to say I knew the exact reason why — we have seen just phenomenal increases in workplace violence,” Lewis said. 

“I have personally seen multiple nurses leave the profession because of injuries that they have sustained and just being fearful of practicing in an emergency department.”

Nurse executive Mary Morin with Sentara Health said this is the fourth nursing shortage she’s experienced in her four decades in the field. 

But this one is “dramatically different” because it’s compounded by shortages in many other health care positions, like doctors and respiratory therapists. 

In the past, where other staff could step in to fill the gap, there are now shortages all around.

“I would say this shortage didn't peak during COVID. We're still in the shortage,” Morin said. “I think we will continue to be challenged with the turbulence.”

Challenges in the educational pipeline

The pandemic also changed the way nursing students were trained. They couldn’t get into hospitals to get hands-on experience with COVID restrictions in place.

Melissa Maxwell, clinical education and nursing practice supervisor for Bon Secours in Hampton Roads, said one graduate told her she’d been mailed blood pressure cuffs and told to practice on a teddy bear or baby doll. 

Sometimes that led to culture shock on the job, Lewis said.

“A lot of them actually left when they were like, ‘Oh my God, this is not what we signed up for,’” she said. “They just didn't have that exposure.”

Nursing students can now get back into the hospital, and Bon Secours also offers new clinical experience on-site.

But despite the market demand, many nursing schools are having to turn away applicants because there aren’t enough instructors to teach them.

Last year, the number of students in entry-level nursing programs fell for the first time in two decades, according to the American Association of Colleges of Nursing. At the same time, thousands of qualified applicants were rejected.

Rising wages for practicing nurses make faculty positions less attractive, according to Old Dominion University’s State of the Commonwealth report last year. Economic analysts devoted an entire chapter to the state’s nursing shortage.

Virginia’s State Board of Nursing also requires that faculty members at four-year universities have a minimum of a master’s degree. 

Walker with the state hospital association said officials are concerned by the current rate of degrees being granted.

“When you contrast that with the overall demand in the marketplace, we are currently and in the future projected to have shortages,” he said.

To combat the problem, ODU’s report suggests that nursing schools consider residency-style programs for faculty to improve recruitment, development and retention. 

It also recommended investing in distance-learning infrastructure, and creating school clinics that serve uninsured or unhoused members of the community while doubling as clinical training sites for students. 

How local hospitals are responding

Hampton Roads health systems are trying a range of strategies to get and keep more nurses on the job.

Morin said Sentara regularly surveys nursing staff “to keep a finger on the pulse around the work environment.” 

The health system has loan forgiveness and tuition reimbursement programs, and uses international recruitment organizations to attract nurses from other countries, including the Philippines and Nigeria.  

Morin said Sentara’s also exploring how to leverage virtual technology.

“Not everything has to be done by a nurse at the bedside,” she said. “It’s a global issue. So we have to think about different ways of how we are going to have to deliver care.”

Maxwell said Bon Secours is working more to recruit directly from university partners, and has launched new clinical practice tracks where students of a nurse residency program can gain experience in a specific specialty, such as the emergency department, surgery or labor and delivery.

The system also upped pay by about 10% over the last two years and added more flexible scheduling options.

Lewis said nurses in today’s market are “looking for a differentiator because they have options now that they've never had before.”

That means opportunities for professional growth and quality of life, not just top dollar, she said. 

Riverside Health System in Newport News said in a statement that it developed two educational incentive programs that offer new hands--on training and educational assistance. 

The programs have “already begun to show positive impacts in increasing the number of health care professionals,” including drawing nine nurses to Riverside, officials wrote. 

Chesapeake Regional Healthcare declined to comment for this story.

At the state level, the Virginia Hospital & Healthcare Association launched a recruiting campaign last year called On Board Virginia. 

“The goal is to essentially tout the virtues for young health care professionals in particular to plant roots and to establish a foothold in Virginia as a place to live and work,” Walker said.

The group aims to build public awareness about the many incentive programs available in Virginia, and push elected officials for policies that benefit health care workers. 

VHHA’s job dashboard currently lists nearly 3,600 open nursing positions — almost a quarter of them in Hampton Roads.

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