Vital Views

Joe Gaccione 0:00
Hello, and welcome to Vital Views, podcast for UNLV School of Nursing. I'm Joe Gaccione, Communications Director for the School of Nursing. We created this podcast to help share tales from our hard-working fantastic nurses out there, whether they're students, faculty, staff, alumni, or donors. These stories focus on work on the frontlines, in the classrooms, in the lab, wherever our nurses are making a difference. But we don't just talk about nursing, we dive into broader healthcare topics to bring attention to bigger issues that impact everybody. We also talk about ways to keep you, your family and your community healthier, both physically and mentally. Nursing shortages have recently been identified here in Clark County and other parts of the country and while it's fair to blame COVID-19 for exacerbating the conditions to make nurses leave, shortages are not just pandemic-based. They've existed for decades before for a multitude of reasons, and eventually resolved themselves depending on the scope, whether there are temporary or regional forces affecting supply and demand, or more national factors. For a series of episodes, we'll explore different aspects of nursing shortages, from current conditions to previous shortages, the causes, the impacts, and what are the most optimal solutions to either avoid or minimize gaps in nursing labor. Previously, part one of our nursing shortage talk focused at the current frontline situation with two UNLV nursing alumni working here in Las Vegas. Today, we're tackling the issue from the faculty perspective. Joining us is Dr. Angela Silvestri-Elmore, Associate Professor at UNLV School of Nursing. She's also a board-certified Family Nurse Practitioner and the program lead for the Traditional Bachelor of Science in Nursing program. Dr. Silvestri, thanks for stopping by.

Angela Silvestri-Elmore 1:48
Thank you for having me. I'm really excited to be here today.

Joe Gaccione 1:51
Now, when you were a registered nurse, did you ever work during a shortage?

Angela Silvestri-Elmore 1:56
That's an interesting question. So, I've been in my teaching role for the last 10 years and I've been a nurse for 12 years. And back in 2010, when I was starting out, I really actually had a hard time finding a job. So that was an interesting thing for me at that time that I didn't expect, because I would hear about the fact that, “We're in a nursing shortage, we're in a nursing shortage,” but then as a new nurse, I really struggled to find a job. And so, for the first couple of years I worked in long-term care, I worked in rehab, and then once I had some experience, it was like, then the opportunities started to come. And so you know, thinking back on that, and then looking back historically, what was going on at that time, there was actually going to be some relief, it seemed, from the nursing shortage at that time. But with little acknowledgement of the fact that the shortages are cyclical. And so, this is where we really have the opportunity to address things in a proactive way. And so, just looking back at some of the dates, back in July of 2010, the tri-council for nursing actually released a statement that cautioned stakeholders about the fact that we shouldn't declare an end to the nursing shortage, because the relief that we were feeling at that time was going to be temporary. And so, this is what, what we encounter, you know, all the time. And there was going to be a slowing of production of RNs, there was going to be demand for nurses, and in the light of healthcare reform at that time, we really could have planned better for upcoming shortages. And so, so, early on initially, in the first couple of years, I didn't really feel that and actually struggled to find a job. But then it wasn't only, you know, two years later, all these opportunities were opening up and it could be because I had a little bit more experience, but I think more so because the demand for nurses was increasing. And so, this is kind of the nature of the nursing shortage.

Joe Gaccione 4:18
Despite shortages being cyclical, do you think we're in a unique situation right now because of the pandemic in post?

Angela Silvestri-Elmore 4:25
Yes, I mean, the pandemic obviously had some major implications on the nursing shortage. But there certainly were problems that existed prior to the pandemic that are not going to go away unless we take deliberate collective action in addressing those issues.

Joe Gaccione 4:46
What kind of problems were there before, from what you can tell?

Angela Silvestri-Elmore 4:49
Well, so, yeah, so there are, there's a lot of these underlying problems that are exacerbated by the pandemic. The number of working nurses hasn't kept up with the aging population, we have increasing complexity of care that requires higher skill set for nurses, we also have higher rates of comorbid conditions with our patients, and then as part of the baby boomer population, we have more than one-fifth of the nursing workforce is going to be retiring in the next five years, at the same time that patients in that same generation are going to require more attuned nursing care. And then, if we kind of bridge into the pandemic a little bit, burnout was always an issue. It's been an issue for a long time, that has been significantly amplified by the pandemic and then, I know we're going to talk about this a little bit later but, perhaps the most important issue is the fact that we have a pervasive nursing faculty shortage. And so that, that, if we address that, we have a potential for a profound impact on the nursing workforce.

Joe Gaccione 6:12
Seems like a lot that goes into it. And when nurses leave, when there's a nursing shortage, it's not always because of something bad, necessarily. I mean, there are nurses that go on to get their advanced degrees. There are nurses that, like you said, retire. It's not because of anything sinister or, or rough. It's just the nature of the business, like with any profession. But you talk about burnout and it's one of those unique terms, because it's not just a cause, it's also an effect at the same time. What can nurses do to try and overcome these feelings?

Angela Silvestri-Elmore 6:45
I think we need to normalize this for nurses. I think a lot of nurses, especially that are working on the frontlines, go through their day-to-day thinking that they are alone in the feelings that they're feeling. And one of the biggest things that I remember as a nurse working in the hospital, is wanting to be able to provide a certain standard of care, but not having the ability to do it, usually because of time or lack of resources. And so, when nurses go into the profession, feeling as though they can make a certain impact and to provide a certain level of care, and then they come to realize that they can't, I think they take some of that on themselves, thinking it's something having to do with them. But really it isn't, it's, it's a systems issue and I don't think that we would find a nurse out there that would, that would disagree with any of this, I think they would all relate to this. And so, what can they do? I mean, short-term, there's things that they can do, but I really only see those as temporary fixes that aren't going to support a long, happy, fulfilled career. You know, I mean, we can do support groups, we can encourage nurses to follow the research on this. So that they realize that they're not alone but that really doesn't address the issue itself. This needs to be at a systems level.

Joe Gaccione 8:22
I do want to get to the systems level comment in a second, but when we talk about the burnout rate, and when it's most likely to occur, is it usually among new nurses that are just getting in or is it more of a long term, over the course of time for experienced nurses?

Angela Silvestri-Elmore 8:37
So, when we talk about separation from the profession entirely, that occurs most often within that first year, because the new nurses, they get out there and they realize, well, this is just not what they envisioned it to be, “I'm gonna go and do something else.” Now, if nurses are able to get past that point, right, they, they get that first year, they start to socialize into the profession more and understand that, “This isn't the only career option that I have,” right, and so, then they might transition into another area where that then helps them to not burn out of the profession entirely. But that first year is really, really important for us to retain nurses in general.

Joe Gaccione 9:24
When we talk about, going back to the systems question, what are the bigger issues that make it so, so much tougher to tackle than just a simple group session or even to tell a nurse, “Hey, suck it up, it's gonna be okay?”

Angela Silvestri-Elmore 9:42
Yes. I think it really kind of goes back to employee satisfaction, right? And what are the things that motivate and encourage employees of an institution to want to stay in that role? Creating mechanisms for feedback, have that feedback heard, have visible changes occurring in the work environment, thereby shifting a culture that is supportive, team-based, doesn't make people feel like they're working in a silo, in a job that they can't do what they set out to do. And so, that really takes action, not just of one person, you know, multiple people. And when we talk about resources, we need more and more and more resources to support nurses in the work that they do. Nurses are so well positioned to understand complex issues in patient care that support the overall health of our society. You know, they are the ones that are right there, they, they know what's happening. But we don't pull on that knowledge or that skill base enough and we leave them feeling disenfranchised, disposable, replaceable. And nurses, because I think of their caring nature, perhaps don't find their voice among other health care peers. So, this is something that I would love to see shifting. And I'd love to see more support on a leadership systems level for the work that nurses do without them having to convince other people.

Joe Gaccione 11:41
Our students see the news, they're smart, they see a shortage going on. How does a shortage impact you as a nurse educator, when you have students that might ask about shortages, or you know they're seeing this and they know they're going to be coming into this workforce and there's going to be holes? How do you encourage them?

Angela Silvestri-Elmore 12:00
The pandemic has made it really hard to be able to talk to students and, and tell them how wonderful our profession is because you feel like you're not telling them the truth, you feel like you're not preparing them for reality. So, the pandemic, right, so we've had to have the National Guard called in to assist, we've had, there's national data that says that one in six hospitals report critical nursing shortages, there's new evidence on trauma related to the nursing role itself, unsafe working conditions, they see this when they're doing their training, they hear about and we talk about travel nursing growing significantly, significantly, right? And so, how to talk to them about getting their first job when they're going to be working with different people all the time because of the turnover rates? And in addition to that, a lot of states took the executive action of issuing temporary licenses to nursing students so that they could be pulled in to aid in the shortage. So, you know, all of these things for a new nurse, I mean, stepping into that role, pandemic aside is challenging, there's such a high level of responsibility, there is so much that they have a direct impact on in terms of how their patients do, in, especially in an acute care or critical situation, but then add all of these things on top of it. So, in the role as a nurse educator addressing this, I feel the most effective way is, is to talk about it in a way that is very realistic and letting them know that, that this is expected because I think the worst thing that can happen is that they go into this role and we have just said, “Oh, it's gonna be okay, it's gonna be okay,” doesn't normalize the feelings that are inevitable once they get to that point. And so, I tried to talk to them to say, “Hey, this is a really hard time right now, but this is a rewarding, dynamic profession. And so, if you feel that you're wanting to step away, I encourage you to talk to your mentors, talk to us, at the School of Nursing, talk to your peers, other nurses, your family, about how you're feeling because there are other options and nursing will still benefit from your skill, even if it's not in that first job or second job that you have.”

Joe Gaccione 14:46
And you mentioned travel nursing before. There are obvious perks to being a travel nurse, the pay number one, you do get to go to new places, and you probably learn more skills that maybe you didn't learn in your previous facility. But it doesn't seem like it's actually helping a shortage, at least on a national level, because you're just moving nurses from one spot to another. But when you move them, you're opening up more holes for that location. So, if anything, it might be helping on an individual hospital or other care center level, but not on a bigger level.

Angela Silvestri-Elmore 15:20
Travel nursing grew by 35%, in 2020, and then an additional 40% in 2021. And looking at this year, it's continuing to grow still. And it's, as you said, both a solution and a problem, because it does attract nurses away from their usual place of employment to new areas, which for that individual nurse could be beneficial, but for that institution, and for that facility, it is not beneficial, and it's not beneficial to our new nurses and training our next generation of nurses to have a constant turnover in the regular staff. It's been very challenging to train nursing students and new nurses during this time because of travel nursing is one of the, one of the main reasons behind that.

Joe Gaccione 16:14
One of the reasons, or one of the ways that UNLV nursing has been able to help stem the tide of these labor holes, at least here in the valley, is through nursing apprentices. I believe as of the past spring semester, we had about 20 students sign up. Can you talk about what a nurse apprentice does?

Angela Silvestri-Elmore 16:29
Yes, absolutely. And one thing that I'll say about that, first is that we've been supported by our State Board of Nursing in doing this work and encouraged to partner with our clinical facilities to make this as seamless of a process as possible for nursing students. And so it did take, you know, a lot of effort on multiple accounts, but it has been working really well and our clinical partners describe it as a game changer for nurses, in particular. We are able to provide support to our nurses, which is so important to us as a school because of what they do for us in training our students and so, so, there are many positions open for new nurses, hundreds at the facilities here in Southern Nevada, there's hundreds of nursing positions open. And so, for nursing students to work as nurse apprentices, which you asked, what can they do and what do they do, they really can do anything that's within the scope of nursing practice, under the supervision of the nurse that they're assigned to work with. And so, that changes as they become more and more comfortable in that role and they become more and more independent in that role. But what we are finding is that students who work as nurse apprentices throughout their program, are then able to step into new graduate positions into an area where they've already got some level of socialization. And they're then seen more supported, right? And so, the feedback has been very positive and our facilities love having the nurse apprentices. And so, I just want to definitely give acknowledgement to all of those who were involved in that response. And I hope to see this as something that is lasting and that we can continue to build upon.

Joe Gaccione 18:35
But the apprentices cannot do more than what they've learned, correct? So, if they were a second semester student, they can only do up to what that second semester will allow.

Angela Silvestri-Elmore 18:44
That's correct. There is some specific guidance that the state board puts out on that. And then, I mean, it's really hard to anticipate every clinical scenario that's going to come up like it's, it's just not possible to do that. But yes, generally, they need to operate within the scope of what it is that they have learned in the program to that point that has been validated. And then after that, if there's other situations that aren’t very clear, then they need to work with their nurse on that with the main consideration being patient safety.

Joe Gaccione 19:18
With the extra experience, and I believe the apprenticeships are paid positions as if they were an employee, what would be a reason that a nursing student wouldn't take up on this offer?

Angela Silvestri-Elmore 19:27
That's a great question and this is kind of a point of contention for me, I will say. The biggest reason why they wouldn't do this is the time factor because we do have a current barrier that I'm working on right now, which is being able to offer academic credit for a paid position is something that not, that is not largely accepted currently. And so, in working on that, from the university perspective, there, there's not a concern there, it tends to be on the individual clinical facility level where we're seeing that stop. And so, kind of the Learn and Earn model, is what this is being referred to as, is supported by our national nursing guiding bodies, AACN and multiple others support doing this, especially in the current pandemic that we're dealing with. And so, again, institution level or clinical facility level is where we're seeing the stop gap to that that I'm continuing to work on, but it's, it's the time factor. So, if we can have students work as nurse apprentices while also awarding academic credit for that clinical work, they would be much more encouraged to do it.

Joe Gaccione 20:52
And I feel like on the clinical side, they would probably be more welcoming to having those, those extra set of hands, even if they can only do so much, that's still more than what you had before.

Angela Silvestri-Elmore 21:03
During the pandemic, there were calls for volunteers for anybody, right? They, they wanted anybody to come in and help. And so we're talking about nursing students who have some level of skill. And as you say, an extra set of hands, and they're eager, they want to be there, they're willing to learn. And so, a lot of times, it's just, it's taking a step back for a couple of minutes to say, “Hey, you've never done this before, let's talk about how to do this, what things you need to be thinking about,” and then the next time, hopefully, usually, they can perform that with a higher level of independence and then as they continue to do that, you know, it's, it's, it is, it just becomes a resource, then to nurses. And so, that's something that I, I hope nurses out there are hearing, because nurses, understandably, feel that they cannot take the time to teach nursing students and when they're approached on a day that they're at work, and they're asked to take a student, what we're encountering now, very frequently, is, “Well, no, I can't because XYZ, you know, I'm so busy, I'm so overburdened, I'm so tired,” and I understand that, 100%, I get that. But we need to shift the mindset of perceiving nursing students as a burden due to the learning needs that they have to, “Well, this person could actually be a resource for me, if I just take a step back here and there as I need to, to give them the guidance they need to make sure my patient is safe, ultimately, they will be helpful.”

Joe Gaccione 22:48
And you're basically playing the long game, because at that moment, yes, they're still students, they know so much, but they're willing to help, you're grooming them, you want them to be more experienced, whatever you can do to help them accelerate that education so that sooner than later, they can be a permanent fixture for you or for another facility. But it's about having that, that patience to say, “It's going to be a little difficult now, but in the long run, it's going to help.”

Angela Silvestri-Elmore 23:15
Yes, absolutely. 100%. And, and at the center of that are the patients, right? And the patients are going to benefit from having another set of hands and set of eyes there that's paying attention to them. So, I do, I encourage nurses to try as much as they can to remember that when they're approached about taking a student because, and we're, I know we still are going to be talking about the faculty shortage, but due to the faculty shortage, we need to rely on nurses working in clinical to function as an extension of faculty to help with the training of new nurses.

Joe Gaccione 24:02
I want to talk about the faculty pipeline. Let's say we had resources to add in X amount of new faculty at a school. What do you think would be the best solution, either having more faculty to bring in more students with the same, you know, class structure, class size, or dividing up those students even more, so you're not taking in more students, but you're dividing up those class sizes, so it's a little more one on one, so to speak? What would you think would be better?

Angela Silvestri-Elmore 24:34
That's a really interesting idea, to be able to divide them up more so that they get more individual attention. I think that would be the ideal situation. However, given the shortage that we're dealing with now, I think in the immediate, the better response would be, and I think this is what we need to do with nursing shortages, is that we need to have mechanisms so that we can proactively respond to these changes, look at them, project them, and then tie that then to how we're enrolling nursing students. But to kind of go back, the immediate needs to be to enroll more nursing students, which is likely going to mean larger class sizes, but then if we're able to get to a point where we have this more kind of evened out in a way where we're able to respond better and we are correcting this immediate need, then the more individualized attention, the better because what we're talking about is preparing somebody to think critically, make judgments, and to make decisions. And so there's a lot of autonomy in that role, it has safety implications and so, the more individualized training that occurs, the better those kind of salient skills are going to be by the time that they graduate.

Joe Gaccione 26:06
Because we talk a lot about patient to nurse ratios, but just as important is the faculty to student ratio, whether it's in the classroom or even in clinicals, because in clinical groups, and I could be wrong, it's like one instructor for every what, six to eight students?

Angela Silvestri-Elmore 26:23
Eight students is the maximum per state board regulation.

Joe Gaccione 26:27
For now.

Angela Silvestri-Elmore 26:28
Yes, for now. Yes. And from time to time, there's deviation from that, it doesn't occur very often, though, because what is the concern is patient safety. And so, depending on what kind of clinical training model you're talking about, you can't be with your students at all times, right? And so, if you have eight students, then you're very likely to be overseeing an aspect of care for eight patients, which if you talk about what that would look like in terms of a nurse to patient ratio, that would be on the higher side.

Joe Gaccione 27:08
Looking at shortages as terms, in terms of a cycle, what you've seen, what we're going through now, do you think there's an upswing coming anytime soon? Or do you think we still have a ways to go?

Angela Silvestri-Elmore 27:19
I think because of the pandemic, we definitely have a ways to go. I think we're still looking at what was the exact ramification of the pandemic in terms of burnout, you know, how many nurses have actually left? How many will continue to leave? And then how many more then do we need to produce? So, I, unfortunately, don't think there's an upswing coming at any point soon. I think we're gonna be dealing with this for several years.

Joe Gaccione 27:52
It makes me think, even though the pandemic was, more or less, declared over despite, you know, upticks in cases, the impacts, the effects, some of them we haven't even seen yet or haven't seen the extent of. So, even though they declare a pandemic over, the longer, the long-term implications are going to be here for a while, that doesn't just go away.

Angela Silvestri-Elmore 28:13
It doesn’t just go away. And we're not able to determine those trends quickly, either because it requires us to look at data from multiple sources to be able to really fully understand, you know, like I said, how many nurses have left and how many intend to leave and then, so adding that on top of the already existing issues that we're attributing or contributing to the nursing shortage. So, so with that, yeah, I think it's here to stay, even though, as you said, the pandemic is, we're talking about aftermath now with the pandemic itself, but then, when it comes to the healthcare workforce, there's definitely going to be ramifications for our while.

Joe Gaccione 29:01
We'll try to end this on a more optimistic note. For current nurses out there, our nursing students, any advice or words of encouragement when it comes to dealing with shortages?

Angela Silvestri-Elmore 29:14
Just know that there are lots of options for you in nursing and it doesn't have to mean that you're working always in an acute care setting. And actually, one way that, that you could optimize your career and then also work to aid in the nursing shortage because every nurse should be concerned about the nursing shortage, it affects their day-to-day. So, thinking about what you on an individual level can do to help is to think about how you could advance your career and advance your education to help to equip you with the skills needed. So, for example, you know, nurses could consider going back and looking at advanced degree options in nursing education or research and those things all kind of interplay together and, and help with, with the shortage itself.

Joe Gaccione 30:13
Dr. Silvestri, thank you very much for joining us today. For everyone else out there, hope you have a great day. Thanks for listening.

Angela Silvestri-Elmore 30:20
Thank you.

Transcribed by https://otter.ai