The nurses are not alright.

That’s the main takeaway from a recent forecast released by UNC-Chapel Hill and NC Board of Nursing researchers earlier this month. According to the data, which is being called NC Nursecast, by 2033, there could be a shortage of nearly 12,500 registered nurses and more than 5,000 licensed practical nurses across the state. And that’s based on data collected before the pandemic.

“It’s been steadily happening for years,” said Meka Douthit El, the president of the NC Nurses Association and the director of nursing for Cone Health Systems about the nurse shortage. “We’ve always been challenged with staffing, but COVID-19 has exacerbated the system.”

According to the data, metropolitan areas will face far greater registered-nurse shortages compared to rural areas after adjusting for population size. And of those areas, the “Northwest/Triad” region which includes Greensboro and Winston-Salem, ranks the worst. For licensed practical nurses, the Triad region fares better, coming in third worst overall behind Western NC and the Triangle. And even though these projections show what could happen in the next decade, El said that she has been talking about how to increase retention of nurses for a long time.

“I’ve dealt with the question of retention and just having enough staff over my entire career,” said El who has been working as a nurse for 25 years. “I’ve felt the heaviness of it moreso within the last five years because people are getting sicker. We’re having to deal with increased complexities of care.”

And that signals one of the reasons why people are leaving the industry, El said. The job is getting harder, and the pandemic just made it worse.

“Over the time of my 25 years, technology has advanced, and we are keeping patients alive and it’s very good to have the technology, but you need the staff to handle the complexities,” she said.

‘Go, go, go, give, give, give’

According to a survey of national nurses released by the American Nurses Foundation in September, 75 percent of respondents noted that they felt “stressed” in the prior two weeks. Sixty-eight percent felt frustrated while a similar percentage noted feeling exhausted. Almost a quarter of the nearly 10,000 nurses said that they intended to leave their jobs in the next six months while 29 percent said they were considering it.

Deborah Napper currently works as a nurse educator and sits on the Guilford County School Board as a representative for District 5. Prior to working as a nurse educator, Napper worked as a nurse in various capacities ever since getting her license in 2005. Back then, she started at Wesley Long in Greensboro, then briefly worked in emergency care in High Point after she had her first daughter in 2010. Afterwards, she worked in home health and in 2017, she returned to working in the ER at Wake Forest Baptist Hospital. Even then, before the pandemic, the job was tough.

“It leaves you with your own version of PTSD,” Napper said. “I had been working nights and I couldn’t sleep.”

During her shifts, she was seeing trauma and burn patients for hours. She treated gunshot wounds and tried to save dying infants. When the hospital started talking about shifting to a military-style triage for incoming COVID-19 patients, Napper said she quit.

“It’s a hard spot to be,” she said.

Even now, months after she left the ER, she says she has a recurring nightmare where blood runs up her legs as she tries to treat a patient who has been shot.

Deborah Napper, GCS School Board Member and nurse educator

“I can hear people screaming,” Napper said.

According to the American Nurses Foundation survey, 47 percent of nurses said they were considering leaving their jobs because it was negatively affecting their health and wellbeing. And because of that, El said she spends a lot of her time trying to act as a support person for her staff.

“I call it doing a pulse check,” she said. “I’ll ask, ‘Are you okay?’ and, ‘Do you need to talk?’ and say things like, ‘You can come to my office and cry.’ It’s important for them to have an area where they can feel vulnerable.”

As COVID-19 hit and nurses were tasked with trying to save patients on the frontlines, they were also having to deal with taking care of their families at home, too. Many nurses quit or had to find different jobs because of the change in childcare and schooling while others opted to take retirement early because of the added stress from the pandemic.

According to a report by Morning Consult from early October, 18 percent of 1,000 health care workers polled for a survey said they quit their jobs during the pandemic and 79 percent noted that the national worker shortage has affected them.

“Some of it we attribute to burnout,” El said about what she’s heard. “For some people, the timing was just right. We go, go, go, give, give, give. Sometimes our families are on the backburner, and we realized that time is short. We have been talking about wellness and balance outside of this work and for some people that meant choosing to step away from the profession.”

Napper also noted that she thinks the highly politicized nature of COVID-19 impacted nurses in a way that health issues didn’t in the past.

“Over the years, nursing has been voted one of the most-trusted professions,” she said. “And then COVID came, and it became very politicized which is something that we’re very much not used to. It eroded the relationship between citizens and medicine in general. I think that’s the single biggest impact of why nurses are leaving the profession.”

‘It’s still worth it’

Both Napper and El noted that the biggest issues facing the industry are lack of Medicaid expansion, stagnated pay and a kink in the education pipeline. If Medicaid is expanded in the state, that would help divert patients away from emergency rooms so they can receive care through the proper channels, El noted.

“We need legislators to push through Medicaid access,” she said. “That will keep people from coming into the emergency rooms and bottlenecking the hospitals.”

According to a June 2020 study published in the Health Services Research Journal, nurse staffing ratios increased in hospitals in states where Medicaid was expanded and hospital-wide readmission rates declined for those same hospitals during 2014-16. El said that she’s also tracking the progression of the SAVE Act or HB 277 and SB 249, which aims to modernize nursing regulations and ease requirements that pose obstacles for nurse practitioners to treat their patients. One of the bill’s primary sponsors is Rep. Joyce Krawiec, a Republican from District 31 representing Davie and Forsyth Counties.

The bill is currently stalled in committee as of March 2021.

Meka Douthit El, the president of the NC Nurses Association and the director of nursing for Cone Health Systems

As a nurse educator, Napper also noted the importance of recruiting new students who will eventually become nurses years down the line. Where she works, Napper said they are having a hard time filling their classes which falls in line with data by the American Association of Colleges of Nursing. According to their data, nursing school enrollment is not growing fast enough to meet the projected demand and that could be attributed to the shortage of nursing school faculty. In their 2019-2020 enrollment and graduations report, AACN noted that U.S. nursing schools “turned away 80,407 qualified applicants form baccalaureate and graduate nursing programs in 2019 due to insufficient number of faculty, clinical sites, classroom space and clinical preceptors, as well as budget constraints.”

One of the biggest reasons for this, El suspects, is the huge gap in pay for nurse educators compared to practitioners.

“If you work in clinical bedside and then you go to teach, there’s a big pay cut,” she said. “Sometimes that’s a $20,000 pay cut and if they are the breadwinners, they have to think about that. But nurse educators do so much.”

That’s why one of the biggest things that the NC Nursing Association is pushing for is addressing the disparities in faculty pay, El said.

“If they can do that then we can increase interest and make that more of an attractive role,” she said. “Then we can increase the pipeline of new nurses coming in.”

Finally, both Napper and El noted that the nurses who are currently working, wherever they may be, need to be treated better and get better benefits.

According to data from the national Bureau of Labor Statistics, NC has one of the highest rates of employing nurses in the country but a median wage of $66,820 that falls well below the national median of $75,330. To combat the shortage, Novant Health, one of the largest health systems in the Triad told Triad City Beat in a statement that they are activating additional staff sourcing through float and on-call pools, contract staff and travel nurses, offering competitive compensation incentives and looking to recruit more individuals for their nurse residency program.

But El and Napper both cautioned against relying too much on travel nurses, who often get paid higher rates than those working directly in the hospitals and act as direct competition to local nurses. Instead, they said that hospital systems need to value the nurses they have currently and make the changes so that the projections for 2033 don’t become a reality.

“The future of nursing can be promising and strong as long as we all pay attention,” El said.

And even though the job isn’t right for everyone, Napper says that if the pandemic has shown anything about nursing, it’s that it’s an incredibly noble profession.

“It’s still worth it,” she said. “It’s not easy right now and with these occupations it’s very easy to let them take over your entire life if you’re not careful but it can still be a very rewarding thing to do. There’s still a lot of good to be done and a lot of care to be given.”

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