Since the covid-19 pandemic hit Arkansas in March 2020, hospitals have at times been overwhelmed with unprecedented patient loads, causing the facilities to carve out bed space anywhere they could, stretch staffing beyond its limits and compete nationally for nurses.
While for years there's been a shortage of nurses, the pandemic exacerbated it. Hospitals have been forced into a national bidding war, with advertisements in Arkansas hawking signing bonuses ranging from $2,500 up to $40,000.
The University of Arkansas for Medical Sciences offers a $25,000 signing bonus for new nurses, an $18,000 referral bonus to experienced acute-care nurses who help recruit another experienced acute-care nurse and a $10,000 retention bonus to acute-care nurses who have been at UAMS for at least three years, said UAMS spokesperson Leslie Taylor.
The use of short-contract travel nurses -- who work for short periods at different facilities -- has multiplied since the pandemic hit.
An Arkansas Freedom of Information Act request to UAMS found that the academic medical system spent $806,131.87 in fiscal 2019 on travel nurses. That number increased more than sevenfold by fiscal 2021, when the hospital spent more than $5.7 million on them. (State fiscal years start July 1.)
The average hourly wage for a travel nurse at UAMS on a 13-week contract grew from $79.15 in 2019 to $94.60 in 2021 -- the equivalent of an annual salary of nearly $197,000.
According to the U.S. Department of Labor, hospital physicians make about $178,000 annually.
A registered nurse on staff at UAMS is paid about $34 per hour, Taylor said.
(Other hospitals in the state surveyed by the Arkansas Democrat-Gazette either did not respond or chose not to answer financial questions. UAMS is a state agency and is subject to the FOIA law, while private institutions are not.)
There are more than 65,000 licensed nurses in the state, according to the state Board of Nursing.
Of that number, 30 are certified medical assistants, 14,431 are licensed practical nurses, 44,719 are registered nurses, 352 are registered nurse practitioners and 5,719 are advanced practice registered nurses.
With more than 110 hospitals and thousands of other medical facilities in the state, there has been a perennial nurse shortage.
'ENGINES OF HEALTH CARE'
The shortage's impact, especially during a pandemic, is significant given the integral role nurses play, said Sue Tedford, executive director of the state Board of Nursing.
Nurses are on the front lines with patients every day. They administer the prescribed treatments and monitor the patients' responses.
"They provide the emotional support for covid patients, since families are not able to stay with them," Tedford said. "Nursing is more than taking vital signs and giving pills. The doctors are not there around the clock, so the nurse is the eyes and ears of the doctor. They [doctors] depend on nurses to see problems that arise in the patients and notify them before those problems are serious."
Bonnie Ward, marketing director for CHI St. Vincent, echoed those sentiments.
"The nurses serving in our ministry are the engines of health care in Arkansas. They're the person providing that direct patient care and doing so with a compassion that in itself becomes part of the healing process," Ward said.
"In truth, they're not only nurses. They're a hand to hold, a shoulder to cry on, a good listener when something needs to be said, and someone to pray with when a patient and their family needs to find strength for what's ahead. CHI St. Vincent, and no hospital for that matter, could provide necessary care without our nurses and their colleagues who are called to this ministry," she said.
CHI St. Vincent employs about 2,500 nurses in its hospitals around the state, Ward said.
"The pandemic has certainly taken a toll on nurses and health care workers everywhere, including CHI St. Vincent here in Arkansas, but that's compounded by the nursing shortage we faced nationally even years before covid-19," Ward said.
Baptist Health employs more than 3,751 registered nurses and licensed practical nurses in various facilities around the state, spokeswoman Cara Wade said.
Staffing continues to be a big challenge. "Most every hospital across the country is experiencing staffing shortages, but the pandemic just highlights an already existing problem," Wade said. "All health care positions are in need, but probably the areas of most emphasis are nurses, doctors, medical technologists, respiratory therapists, radiology and patient care technicians."
"Nurses are important to everything we do throughout Baptist Health," Chief Executive Officer Troy Wells said.
"There's always a nurse by every single patient. But that nurse is also part of a broader health care team made up of different types of caregivers, health care professionals, and hospital support staff -- and that team is frequently also led by a nurse," he said.
Cindy Curtis has been a nurse at Baptist Health in Little Rock for 15 years, first as a licensed practical nurse before earning her registered nurse certification.
Today, she works multiple 12-hour shifts each week, caring for covid-19 patients in the intensive care unit. It's a job she views as a ministry.
"I've gotten really good at praying for my patients and being a family for my patients," Curtis said. "You have to love them like they're yours because their people are sitting at the window" on the ground floor of the hospital looking in.
Shannon Nachtigal, chief nursing officer at Baxter Regional Medical Center in Mountain Home, said that rural-area hospital has more than 600 nurses, but is still struggling to stay fully staffed.
Nachtigal said that in the six years before the pandemic, the hospital never needed travel nurses. But in the past year, it has contracted with about 40 temporary nurses.
"I don't think there are words that can describe how truly important nurses are to health care," Nachtigal said. "Nurses are the only consistent people in the world that are between the patient and the outcome, meaning it is the nurse that is there helping the patient heal, and it is the nurse that is there when the patient does not heal."
Arkansas Children's Hospital employs 47 licensed practical nurses; 1,665 registered nurses; and 12 advanced practice registered nurses, and is struggling to stay fully staffed because of increased demand, limited new graduates in the profession and higher rates of nurses leaving, said Jamie Wiggins, executive vice president and chief operating officer.
"For Arkansas Children's, nurses are a lifeline that ties together our many disciplines and contribute tremendously to the compassionate environment in which young patients thrive," Wiggins said. "Despite the pandemic's toll, Arkansas Children's has retained many long-tenured nurses."
The state Health Department is also facing a nursing shortage, with 49 vacant registered nurse positions and 19 vacant licensed practical nurse slots, spokesperson Danyelle McNeill said.
The department employs 292 registered nurses at an average wage of $33.30 per hour, and 53 licensed practical nurses at an average of $22.02 per hour. The Health Department also employs 19 extra-help registered nurses at $30.78 per hour and two extra-help licenses practical nurses at $17.38 per hour.
"We don't employ travel nurses of any kind," McNeill said.
All of the hospitals surveyed by the Democrat-Gazette contract with travel nurses to meet the demand during the pandemic, but only a few other than UAMS would release the associated costs.
Baxter Regional's expenses went from zero to more than $500,000 annually.
Arkansas Children's Hospital has spent about $3 million on travel nurses in the past 12 months, spokeswoman Hilary DeMillo said.
After initially being spared a flood of patients when the pandemic started, patient volumes associated with respiratory syncytial virus and the delta variant of the coronavirus surged this summer. That drove children's hospitals to have to increase their use of travel nurses, she said.
Ward, while not providing travel nurse expenses for CHI St. Vincent, said the average cost for the temporary nurses has "increased through the pandemic."
Wade said Baptist Health has always used traveling nurses from time to time and is "certainly using that market now."
"Without giving specific numbers, we've used more travel nurses this year than ever before," Wade said.
Travel nurses, unlike on-staff nurses, do not receive employee benefits.
Curtis, the staff nurse at Baptist Health, loves the hospital but admits she is frustrated about the influx of traveling nurses she now works beside -- most making three times more than she does.
"We appreciate the help," Curtis said. "But it's hard to be a nurse in a place that you've never worked before. We do struggle with educating them in our ways. It's about on-boarding them quickly, then knowing that along the way you're going to have to stop a little bit of what you're doing to help them be able to meet the demands and the quality measures that Baptist has in order to have good patient outcomes."
FUNDING THE NEED
Since March 2020, when the state had its first covid-19 patient, Arkansas hospitals and other entities received millions of dollars in federal funds to increase their patient capacity.
The state Health Department granted more than $66.3 million from the federal American Rescue Plan Act to five Arkansas hospitals.
McNeill said there is no specification of the amount dedicated solely for nurses.
Of the funds, $10,540,000 went to Unity Health in Searcy; $37,680,000 to Baptist Health; $12,420,000 to CHI St. Vincent; $2,736,000 to the Jefferson Hospital Association in Pine Bluff; and $3 million to St. Bernards Medical Center in Jonesboro.
The Health Department received $507,954 in federal relief funds from the Coronavirus Aid, Relief, and Economic Security Act to pay the salaries of extra-help nurses.
Last month, the Arkansas Legislative Council's Performance Evaluation and Expenditure Review Committee endorsed a request to use about $5.6 million in American Rescue Plan funding for UAMS to attain and retain front-line health care workers.
The state Department of Human Services received $80 million from the CARES Act for "direct care workers in hospital settings," as well as payments to non-health-care personnel in hospital settings and non-health-care personnel in institutional settings, according to data provided by the state Department of Finance and Administration.
Another $50 million was designated from the CARES Act to the Department of Human Services to "enhance hospital facilities capacity" because of the covid-19 surge.
About $129.2 million was designated for the Human Services Department from the American Rescue Plan Act Steering Committee for "surge staff funding," according to the data provided by the Department of Finance and Administration.
As of late Friday, Human Services Department spokeswoman Amy Webb said specifics on how much was spent for nurses were not yet available.
Aside from the costs of travel nurses, Arkansas hospitals are having to up their games to retain nurses.
Elizabeth Sullivan, the intensive care unit nursing manager at UAMS, said several staff nurses have left for more lucrative travel nurse opportunities.
"We've had a huge success rate of maintaining staff. Our unit is a family," Sullivan said. "But it really is a challenge now."
UAMS Chief Nursing Officer Trenda Ray said the bond of the medical team is what keeps a lot of nurses from leaving, but staffing shortages make using travel nurses a necessity.
"It is definitely a battle. Historically, when nurses were in short supply, they were pretty mobile and they would move around. It was not uncommon," Ray said. "It's just now escalated based on the demands of the market. There's compensation opportunities that nurses can't pass up."
Hospitals have taken steps to retain staffing.
In addition to new-nurse signing bonuses and retention bonuses, UAMS has provided incentives such as direct and nondirect care payments, critical staffing pay and merit increases.
"We continuously are monitoring the external market for benchmarking our current RN pay practices and making adjustments," Taylor said.
Nachtigal said Baxter Regional does what it can to let nurses on staff know they are valued. Nurses on the payroll at Baxter Regional get the usual benefit package of retirement, insurance and overtime pay, but also receive covid-19 premium pay.
"We have a concierge that offers oil change, dry cleaning, laundry, car detail, groceries and homemade breads," Nachtigal said. "We have brought in a massage therapist for head and neck massages. We have certified stress debriefing counselors for our nursing staff."
St. Bernards Healthcare in Jonesboro uses signing bonuses and employee referral bonuses, as well as enhanced pay for overtime and extra-shift options, spokesman Mitchell Nail said.
Ward said that at CHI St. Vincent's, while some nurses have left for traveling positions, some traveling nurses have left the circuit and joined the hospital's staff full time.
"Throughout the pandemic, we have offered our employees many additional resources to help make their workdays a bit easier. These include offering free meals; emotional support with virtual counseling services or local chaplaincy; free access to sites like care.com so they can find the child care they need; and even virtual workout classes to help manage stress," Ward said.
Wiggins said most recent resignations at Arkansas Children's Hospital have been to pursue travel nurse assignments "to make three or four times their normal salaries."
Also, "nationally, we are seeing increased numbers of nurses leave the profession all together or take early retirement," he said.
In addition to the typical employee benefits, Children's Hospital adjusted base wages, increased incentive pay for extra shifts, increased bonus payments for nurses who pick up extra shifts, and implemented a retention incentive for nurses, Wiggins said.
Baptist Health offers premium pay for nurses on staff and gave assistance during the early phases of the pandemic before vaccines were available, Wade said.