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A rapidly aging population, increased incidence of chronic illnesses, and expanded access to care due to health care reform all place an additional strain on hospitals that are already struggling to maintain an adequate workforce. Although the lack of registered nurses is the most widely publicized problem, shortages exist across the entire industry and includes, among others, pharmacists, radiology and laboratory technicians, and mental health professionals (Burroughs, Suh, & Hamann, 2012).

This is especially true in rural hospitals where even in normal circumstances, the demand for services is already known to regularly exceed their ability to adequate supply them. The Problem Limited financial resources present significant challenges to the rural hospital and “low- patient volumes make it difficult for these organizations to manage the high fixed costs associated with operating a hospital” (American Hospital Association, 2011).

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The shortage of healthcare workers exacerbates this problem by making it more expensive to recruit and retain both clinical and support staff resulting in fewer opportunities for rural patients to get access to the healthcare they need, keeping patient volumes low, and forcing already over-worked healthcare workers to work even harder. A report from the Rural Assistance Center (2013) presents several reasons for this problem, including: ?A lack of educational and training opportunities ?

A lack of opportunities for career advancement ?The perception of lower pay and benefits in exchange for increased workloads There are, of course, many other factors that contribute to the shortage of healthcare workers, (an aging workforce, increase in demand due to healthcare reform, more lucrative employment opportunities in non-clinical settings, and fewer healthcare educators, just to name a HC WORKFORCE SHORTAGE 2 few) but this short list represents three factors that are within a hospital administrator’s ability to influence directly – by changing the way that they look at recruitment and retention, rural hospital administrators can formulate strategies to help address these issues and better cope with the ongoing threats to the healthcare workforce.

Financial and Other Risks According to the U. S. Census Bureau (2010), rural populations tend to have lower-than-average incomes, are more likely to suffer from chronic illnesses, and less likely to be insured than their metropolitan counterparts (American Hospital Association, 2011). Like the rest of the population, rural residents are also rapidly aging.

This applies not only to patients, but also to the healthcare workforce. In 2003, more than 50% of healthcare professionals were already over the age of 40 (GHA, 2011), and in 2001 at the peak of the workforce shortage, many hospitals reported that expenses for RN recruitment and retention had increased by up to 75%.

Many also reported paying sign-on bonuses to staff in shortage areas, and substantial shift differentials for working the least desirable hours (FCG, 2001, p. 13). In fact, more than 40% of the hospitals who participated in an American Hospital Association survey in 2001 reported offering sign-on bonuses in order to recruit new clinical staff (FCG, 2011, p. 13). Unfortunately, this often created morale issues among the already over-worked existing staff. Some hospitals have been able to patch together a schedule with agency staff, however, staff irregularly employed through outside sources are rarely familiar with the policies and processes of the hospital.

This places additional burden on the existing staff who must support them, may compromise patient satisfaction and, ultimately, patient safety. In addition to costing hospitals nearly twice as much as employing regular full-time staff, hiring agency nurses may also create problems with morale among the existing staff, especially nurses: “Full-time nurses are very resentful of the agency nurses that are brought in for more pay, that name their own hours, and walk off when the shift is through” HC WORKFORCE SHORTAGE 3

(CSG, 2003). All of these things can severely undermine a rural hospital’s staff retention strategy, no matter how carefully it is formulated. Retention and Recruitment Although the healthcare workforce crisis cannot be resolved by hospital administrators alone, the American Hospital Association (2001) offers some suggestions on how focusing their attention on employee retention can help hospitals find some relief: ?Foster Meaningful Work.

Administrators should evaluate their systems and processes to examine and re-define job responsibilities to provide balance and help create a more rewarding work experience for all staff. ?Improve the Workplace Partnership. Administrators should examine the culture or their organization to ensure that it is conducive to building employer-employee relationships.

Hospitals should consider human-resources a part of their organization’s strategic plan and not as just a necessary function of operations. ?Collaborate with Others. Administrators should pursue opportunities to work with other hospitals and healthcare providers, educational institutions, and community leaders to help find ways to lessen the impact of healthcare workforce shortages.

Administrators can also work to improve the perception of rural hospitals by accentuating the benefits to professionals who work for them. Physicians in rural areas may work slightly longer hours than those in urban areas, for example, but they make an average of 13% more when their salaries are adjusted for the cost of living (Reschovsky & Staiti, 2005). The success of these and other efforts can be easily measured by examining employee retention rates and by employee satisfaction ratings. Recruitment numbers should also improve as collaborative relationships are developed, but if these efforts are not adequate, there are other options available.

Organizations can develop in-house training opportunities for allied health professionals who may not have the means or the opportunity to obtain a diploma or certificate in a more formal educational setting, and cross train technicians in areas where shortages frequently HC WORKFORCE SHORTAGE 4 occur.

Because rural hospitals are often responsible for meeting many of the primary care needs of the community, they can also train mid-level providers to assume a portion of physicians’ workload. In their meta-analysis of research on the performance of mid-level providers, Lassi,Cometto, Huicho, and Bhutta (2013) found that in many cases, clinical outcomes met or exceeded those achieved by physicians, and that patient satisfaction levels were often higher when care was delivered by mid-level providers.

The study found that mid-level healthcare staff are much easier to retain in rural areas, but the authors also note that it may be difficult to implement new training strategies in areas hardest hit by workforce shortages. Lassi et al. (2013) therefore advise those who consider this tactic to remember that “any task-sharing strategy should be implemented alongside other strategies designed to increase the total number of health-care workers”.

One such strategy might be to recruit foreign nurses, or for a more long term solution, to support recruiting efforts aimed at minority populations within the United States. Conclusion Hospitals often have to make do with very limited resources, and this is especially true for those that provide care in rural areas of the United States. Much has been written about the healthcare workforce crisis in the rural United States, but very little has been written about how to resolve it.

Rural hospitals must address the issue by developing and deploying effective recruitment and retention strategies. Although attention to these two areas will not permanently solve the complex and ongoing problem of the healthcare worker shortage, it would be wise for hospitals administrators to approach them as though they were the only solution. Increased demand for services and payment systems based on healthcare quality, safety, and patient HC WORKFORCE SHORTAGE 5 satisfaction will require organizations to maintain a stable workforce of skilled professionals and support staff now and in the future. References AHA Strategic Policy Planning Committee. (2001, January 23).

Workforce supply for hospitals and health systems: Issues and recommendations. Retrieved from http://www. aha. org/advocacy-issues/workforce/inourhands2001. shtml American Hospital Association. (2011). The opportunities and challenges for rural hospitals in an era of health reform. Retrieved from Author website: http://www. aha. org/research/reports/tw/11apr-tw-rural. pdf Bloor, K. , & Maynard, A. (2003). Planning human resources in health care: Towards an economic approach.

Retrieved from Canadian Health Services Research Foundation website: http://faculty. mu. edu. sa/public/uploads/1360249287. 103human %20resource157. pdf Burroughs, E. , Suh, R. , & Hamann, D. (2012). Healthcare workforce distribution and shortage issues in rural America. National Rural Health Association. First Consulting Group. (2001). The healthcare workforce shortage and its implications for America’s hospitals (Fall 2001). Retrieved from Author website: http://www. aha. org/content/00-10/FcgWorkforceReport. pdf Georgia Hospital Association. (2011, September 15).

Report on the 2010 Hospital Workforce Survey. Retrieved from: https://advocacy. gha. org/Portals/1/Documents/Advocacy/ Workforce/datastatistics /2010SurveyReport. pdf Lassi, Z. , Cometto, G. , Huicho, L. , ; Bhutta, Z. (2013, May 30). WHO | Quality of care provided by mid-level health workers: systematic review and meta-analysis. Retrieved from http://www. who. int/bulletin/volumes/91/11/13-118786/en/ Reschovsky, J. , ; Staiti, A. (2005, January). Issue brief nbo. 92: Physicians incomes in rural and urban America. Retrieved from http://www. hschange. com/CONTENT/725/

Rural Health Care Workforce Frequently Asked Questions – Rural Assistance Center. (2013, May 28). Retrieved from http://www. raconline. org/topics/health-care-workforce/faqs The Council of State Governments. (2003). Building tomorrow’s healthcare workforce: State strategies for today. Retrieved from http://www. csg. org/knowledgecenter/docs/hpm03wi- BuildingTommorrows. pdf U . S. Census Bureau. (2010). Current Population Survey, 2008 and 2010 Annual Social and Economic Supplements. Retrieved from http://www. census. gov/hhes/www/hlthins/data/incpovhlth/2009/tab9. pdf.

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