You've probably heard a story about a friend or loved one who went to the emergency room in Humboldt County and had to wait hours to be seen. Or maybe after getting into the ER, he or she was transferred to an intensive care unit out of the area. "Not enough beds," "not enough doctors," go the tired and true refrains. But those are far from the only or the most frequent limiting factors.
"There are beds in the county — plenty of hospital beds in the county — there just aren't the nurses available to give you care," explained Sara Isaacson, chief nursing officer at Mad River Community Hospital.
As an example, Isaacson pointed to the hospital's intensive care unit, which has enough rooms to accommodate six patients but has to be staffed with a nurse per every two patients. When the hospital can only find two nurses to work an ICU shift, it has to limit ICU admissions to four patients, meaning anyone else will have to be sent to another hospital or held in emergency discharge until a patient leaves the ICU.
"That's the game that sometimes goes on all day long," Isaacson said. "There is a bed, there just isn't a bed with a nurse attached to it. Every day, it's a limiting factor and it's hard because on the horizon, it doesn't look better."
The official numbers put Humboldt County just on the cusp of designation as a "registered nursing shortage area" by the California Office of Statewide Health Planning and Development (OSHPD). But just about everyone in the local health care industry concedes there is a shortage, one that impacts patient care, hospital staffing and provider budgets.
And the numbers indicate Humboldt's problem is getting worse, and fast. Back in 2010, the county had about 1,500 registered nurses, according to data from OSHPD. By 2012, that number had dipped to 1,483. Two years later, it fell to 1,451. In 2015 it came in at 1,401, marking a 7 percent drop over six years.
"It's been pretty steady," said Pat Farmer, a local nurse practitioner who works as a nurse expert consultant for the Center to Champion Nursing in America, a national initiative working to improve healthcare through better use of the nursing workforce. "I think it's a very substantial problem."
While exacerbated by a number of factors, Humboldt County's trend isn't unique and many — including Farmer and Isaacson — feel a national nursing shortage isn't far off. According to a 2014 report by the American Nursing Association, 53 percent of the nation's almost 3 million working nurses were over the age of 50. Many believe a national nursing crisis was simply delayed by the great recession, which kept many in the workforce longer than they'd planned and sent others scurrying out of retirement.
Humboldt County, with its rural isolation and socio-economic challenges, also faces a unique set of hurdles. Those were made worse back in 2011 when Humboldt State University, in the midst of an intense budget crunch, shuttered its nursing program, closing a supply line that had been graduating about 60 students a year into the local community with Bachelor of Science degrees in nursing. College of the Redwoods, meanwhile, sends about 60 graduates into the nursing workforce annually with associates' degrees, but area hospitals and medical facilities are already hurting from HSU's closure.
"We cut the supply chain in half," Farmer explained. "It just defies common sense to think that's not going to have a substantial impact."
Now, six years later, it appears there's a universal recognition of the need for a program that will both bring more nurses into the local workforce and give the ones here opportunities for advanced education. To that end, Connie Stewart, executive director of HSU's California Center for Rural Policy, said the North Coast Health Leadership Team — a regional group of healthcare and human services CEOs — recently discussed local nursing needs with representatives of both HSU and College of the Redwoods, and the parties have continued to meet with the aim of improving healthcare career pathways.
Back in 2011, when then Humboldt State University President Rollin Richmond announced in a campus-wide email that the school's decades-old nursing program would shut down, the program was at once successful and foundering.
Its graduates were universally hailed as well trained and prepared to enter the workforce. The program was impacted, with a line of students waiting to get in, and it was one of the few at HSU — or most other places — in which graduates could grab their diplomas and walk into the real world with virtual certainty they would find a job in their chosen field.
But the program was also clearly dysfunctional. It had been having a terrible time recruiting tenure-track faculty. Even worse, according to then HSU Provost Bob Snyder, the program, when given an exemption from a campus-wide hiring freeze in 2010, its administrators failed to put together a committee or come up with hiring criteria. When asked to formulate a plan with clear goals and benchmarks for improvement, the program submitted nothing. A couple of months before Richmond's email, the program director, Martha Libster, who had been handpicked by administrators just a few months earlier from out of state to come in and lead the department, resigned citing a hostile work environment.
At that point, the program had already been given a reprieve. In the spring of 2010, with HSU facing a massive, recession-fueled budget deficit, administrators were looking to cut the school's academic affairs budget by $7 million and asked the Academic Senate to recommend program eliminations totaling $1.3 million. Nursing was at an automatic disadvantage in this process, which asked faculty members to choose which programs — and which colleagues' jobs — to cut.
The nursing program cost the university about $900,000 annually (nursing programs are inherently expensive because they require extensive in-the-field supervision) making it far and away one of the most costly on campus. If the senate chose to save nursing, it would have had to cut a plethora of other programs to arrive at the same savings. So in April of 2010, the senate recommended that nursing get the ax.
But a community outcry ensued, with local hospitals, editorials and elected officials all pointing out the desperate need for the program and its great value to the county as a whole. Richmond granted the program a reprieve but it was clearly on thin ice. Just about nine months later, its fate was sealed. At the time, many close to the program felt HSU administrators — tired of the department's internal turmoil and its high price tag — had simply allowed the program to wither on the vine, refusing to intervene when it was clearly struggling. (For his part, Snyder said it would have been inappropriate for administrators to step in and guide hiring processes or help the department formulate a plan to save itself.)
Whatever the exact reasons and motivations, the program shuttered, with its last graduates crossing the Redwood Bowl stage in 2012.
"It's water under the bridge," said Pat Gircyc, director of CR's nursing program at the time. "Let's look at where we are now and what we need to do in this totally changing landscape."
Health care has changed dramatically in recent decades. People are living longer — and living longer with chronic diseases. And there have been dramatic advances to make surgeries less invasive: While having a knee replaced used to require a weeklong hospitalization, patients now often go home the next day. Someone getting a gall bladder surgery, which once required a 10-day stay, today might go home as soon as the anesthesia wears off.
These advances have changed nursing in two fundamental ways. First, it has pushed some of the demand for nurses out of hospitals and into homes and rehabilitation facilities. Second, it has made hospital work much more complex.
"People in the hospital are just a lot sicker than they used to be," Gircyc said.
This means the demands of nursing education have also changed. There are three routes to becoming a registered nurse in the United States: a three-year diploma program typically administered in a hospital; a three-year associates degree (AA) obtained through a community college; or a four-year baccalaureate degree (BSN) through a university. Graduates of all three programs need to take the same licensing exam to work as registered nurses.
But the healthcare world is gradually demanding that more and more nurses get a BSN, which opens the door for advanced degrees and leadership roles. In fact, a BSN is now required to become a public health nurse or work for the VA Clinic. In California, Farmer said about 10 percent of employers require a BSN and 70 percent prefer one.
And data seems to support the shift, as a host of studies have found that hospitals with more highly educated nursing staffs tend to have better patient outcomes — judged by everything from patient mortality to infection rates. This is certainly not to say that a nurse with a BSN degree is inherently better than one with an AA degree, but the data indicates that, on the whole, more education is a good thing. In fact, back in 2010, the Institute of Medicine released a landmark report calling for 80 percent of the nursing workforce to hold a BSN by 2020.
This represents a unique challenge in Humboldt. With the closure of HSU's program, the county lost about half of its nursing graduates entering the workforce. But it also lost 100 percent of its BSN nursing graduates. At the time, administrators at both CR and HSU said they recognized this need and pledged to work diligently to create some kind of distance learning program that would allow CR's students to enroll in another California State University and pursue a BSN degree. For reasons that aren't entirely clear, no formal program was ever created but even such a so-called "bridge" program would only solve half of Humboldt County's problem.
"That's not going to address the overall shortage of nurses," Farmer said.
Almost five years after HSU's last nursing graduate entered the local workforce, the future of nursing in Humboldt County isn't entirely clear. At Mad River Community Hospital, Isaacson said she's constantly scrambling to find and hire nurses, even at a hospital that enjoys better retention numbers than most.
Nurses are in such demand, Isaacson said, that the registry — or traveling — nurse industry is booming. This means there's little to tie younger nurses down. If someone wants to spend time traveling, maybe working a few months and then taking a few months off, he or she can. "The millennial generation is so mobile," she said. "And, if they're good, they'll have work whenever they want it."
This means that, in a pinch, Isaacson, St. Joseph Hospital and others will pay a registry agency $115 an hour to staff a nursing position for 13 weeks at a time. While this is far better than not having a nurse to fill a shift, it's far from ideal. The cost is exorbitant, and the shift is being filled with a nurse who was trained elsewhere and isn't fully integrated with the facility or Humboldt County's unique — and extensive — public health needs.
While many options have been explored — Isaacson said Mad River Community Hospital even looked into buying up housing to offer up to traveling nurses with the hopes of luring them into staying a while on the North Coast but decided it would require too big of an investment — most come back to the need for some kind of opportunity for advanced nursing education locally.
Gircyc said she personally sees a lot of momentum in this direction, saying that "it's on everyone's radar." But, she said she doesn't want to see HSU's old program simply revived. "What we need is something really out of the box and innovative that meets the community needs," she said.
Most agree that this would be some kind of collaborative effort between CR, HSU and local healthcare providers. The ideal would be a program that allows CR's nursing program, which has a lengthy waiting list, to increase enrollment in a partnership with HSU that would feed graduates into a BSN program, where they could finish their last year or so of post-licensure classroom work to graduate with a BSN.
This would prove less costly for HSU, as much of the expense of nursing programs comes from the first years, which require in-field supervision and low student-to-faculty ratios.
Currently, there are a host of online BSN programs available to nurses working with an AA degree but it's often hard for working nurses to return to school and, even when they do, they can run into requirements — like prerequisites — that necessitate their going back to school before enrolling. And even when working nurses do get into an online BSN program, they receive a generalized education that lends no Humboldt-specific perspective.
A true partnership between a community college and a university streamlines this process, ensuring students can step directly from the AA program into a BSN while receiving a localized education at every step.
It's clear there is a problem in Humboldt County with a larger one on the horizon and they're not going to resolve themselves. If Sara Isaacson is ever going to rest assured that her ICU will be filled to capacity with patients and the nurses to care for them, the community is going to need to find a solution. And Farmer, the national consultant who works locally and got her AA degree from CR, said that solution needs to come sooner rather than later.
"I don't think it's going to take five to 10 to 15 years for the problem to blossom locally," she said. "It's pretty widely accepted that we are headed toward a pretty significant nursing shortage."