Covid-19 has been on the forefront of everyone's minds for over a year now, but the biggest crisis for health care providers in 2021 might not be the pandemic—it may be nursing shortages.

Radio Advisory's Rachel Woods sat down with Advisory Board CNO Carol Boston-Fleischhauer to talk about the nationwide shortage of nurses and what hospitals can do now to address some of the bigger problems nurses face today.

Read a lightly-edited excerpt from the interview below, and download the episode for the full conversation.

Rachel Woods: So then let's talk about what it would really take to stabilize the workforce. Now, I'm not sure the right way to think about this is as purely a Covid-19 problem. Obviously the pandemic has made this a lot worse but are there underlying reasons that existed before the Covid-19 crisis that showcase the fragility in the nursing workforce, especially in the inpatient space?

Carol Boston-Fleischhauer: Yeah, it's interesting—a lot of folks may have forgotten but we were already facing a growing nursing shortage. Pre-pandemic, many organizations were starting to grapple with that issue on how to retain their nurses, especially their novice nursing staff from leaving within the first one or two years of employment, unfortunately and understandably organizations had to prioritize Covid readiness and Covid care over just about everything else. So things like focusing on vulnerable engagement drivers and professional development and all the things that we normally do to retain employees were suspended. The problems are still there.

It is to say that in addition, however, to the preexisting conditions of a very complex care environment that we were trying to retain nurses in pre-Covid. The damage that staff incurred during Covid has left indelible marks on them.

Everyone has seen the data, we've got more mid-career nurses taking extended furloughs to regroup, if not leaving their jobs, if not the profession altogether because of what's happened to them. We've got a battered workforce here. That's been through a lot and we haven't addressed the pre-existing Covid conditions that we were dealing with prior to Covid hitting our organizations as well.

Woods: So what you're telling me is that this is not a problem that is going to go away if and when the pandemic wanes. Now let me force myself to take a positive take for a moment. The one glimmer of hope that I have is that people are talking about this crisis who are not just nurses or who are not just nurse leaders.

I have never before in my career had so many executives, CEOs, CFOs COOs, these core members of the executive team come to me and you and our colleagues at Advisory Board and say, "Help me combat this workforce issue." We talked a little bit about the CFO concern. What are you hearing specifically from the CEOs?

Boston-Fleischhauer: Well, from CEOs, I'm understandably hearing all sorts of concern regarding the continued commitment to making certain that the organization or the system safely provides high quality care at the same time, making certain that beds stay open and services are offered in order to support the health care needs of the community. And so CEOs clearly have got a vested interest in safe, efficient staffing as an alternative to closing beds, closing services and obviously impacting revenue.

We've got chief medical officers expressing the same concern. If they can't get a case on because you've got a shortage of perioperative staff or you can't admit a patient into an organization because beds are closed. Physicians are frustrated because of the care that their patients can't have at the same time, as a consequence of the staffing shortage. This has got a ripple effect across everybody. This is not a nursing labor issue. This is a strategic challenge.

Woods: And I agree with you completely, especially on some of these ripple effects. When we start to think about safety, when we start to think about never incidents happening, I actually had one physician leader say to me, pretty bluntly, "Nobody is working at top of license at my hospital."

I don't know if that's a sentiment you've heard but I hate to say that really it's rolling downhill. And I've heard from nurses that they are cleaning rooms, delivering food. This is not something that is just impacting one aspect of the workforce it's impacting everyone.

So this is a strategic issue and it's an issue that you're hearing from CMOs, from CEOs. I want to come back to the CFO for a moment. We talked about the cost side of the equation. Needing to write these massive checks but I'm guessing they're also very, very concerned about the revenue side of the equation.

Boston-Fleischhauer: I know that many organizations are being forced to use some sort of sign-on bonus incentive, as well as augment their permanent staff with increased use of traveler nurses—why? To keep beds open, to keep revenue flowing, to keep services available for members of their community.

But it is only to say that if the only thing an organization invests in is incentives for new hires and acquisition of traveler contracts over an extended period of time. As I mentioned before, that expense is going to continue to be hitting your organization's bottom line, which is why as it relates to sign-on bonuses for example.

We're seeing an increased number of organizations say, "You know what, I'm going to use a little bit of a sign-on bonus but I'm also going to use a retention bonus. I'm going to incentivize employees that stick with us versus use that precious pool of money only to attract new people in or I'm going to use some of that money for employee referrals so that we can, once again, reward our employees who are talking to their friends or their colleagues throughout the community to see if in fact employees can bring new candidates into the organization without these outrageous sign-on bonuses."

So, there's a limited amount of money. The question is where do you invest it to get the best return on investment that you possibly can?

Woods: And if you're forced to make one of these Band-Aid moves, it sounds like you're starting to at least hear from some folks that they're connecting that desperate move to something else. It's the sign-on bonus and because we know that this has to be temporary, otherwise we're just going to be making the problem worse.

Boston-Fleischhauer: Well, you're raising an interesting assumption there. And that is that people would presume that this is not the only set of things that we need to do. I'm just saying Band-Aid solutions are just that, they have a place, they have a purpose but to only use investment money to support Band-Aid solutions will do nothing to turn the situation around within your organization.

So the question is, if you've got a finite amount of money, how do you use some of it to support the immediate staffing needs of your organization in order to ensure that beds stay open and services are available within the next month but at the same time, invest in what it is that registered nurses are saying is pushing them out the door in the first place?

Woods: And what is it that frontline nurses are saying they want from their employer?

Boston-Fleischhauer: Well, number one, registered nurses are saying, "I am leaving this inpatient environment because of the excessive workload and not enough support." You mentioned earlier Rae, this notion of registered nurses being forced to do all sorts of things that are not at top of license. Absolutely that's the case.

So, how is it that an organization says, "We want to protect our registered nurses. We want to make certain that they can practice at the top of their license and their capability but we shouldn't have to rely on our registered nurses to pass trays and to empty garbage and to change beds and things of that nature, unlicensed sets of activities."

So enter the entry level worker strategy. We're seeing smart health care organizations say, "Boy, we've got to develop a pipeline here for support staff to support our registered nurses so that they don't feel as if they're not getting the support that they need."

This is tough for provider organizations because entry-level workers in every industry are a hot commodity right now. And hospitals unfortunately, are now competing with the likes of McDonald's and Walmart and Costco, and so not only do entry level salary levels have to be looked at but also what else are you providing for these folks so they'll stick with you as well? 401ks and PTO and professional development. That's what an entry level worker is looking for. No different than what a professional worker is looking for as well.