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This Valley health system closed more than 100 psychiatric beds last week. Here's why

A bed at Valleywise Health Medical Center sits empty.
Stephanie Innes
Arizona Republic

One of the Valley's largest providers of inpatient psychiatric care closed more than a quarter of its beds last week because of a staffing shortage that is affecting patients across the public health system.

Closing psychiatric beds means that some patients face long waits in emergency departments or in areas of hospitals that haven't been designated for psychiatric patients, which is not optimal for people in a mental health crisis.

"Any stress on inpatient psychiatric beds in Arizona is a burden and not great for patients and hospitals," said Dr. Frank LoVecchio, an emergency room physician at Valleywise."Patients often wait one, even days, in the ER for an inpatient psychiatric bed."

Phoenix-based Valleywise Health, a public health system that serves a large percentage of vulnerable patients, has long been accustomed to seeing high turnover rates for behavioral health technicians. But not among nurses that specialize in behavioral health care. 

"Traditionally we have had very limited turnover in the (behavioral health) RN role," Valleywise chief nursing officer Sherry Stotler said.

"It wasn't until the pandemic started that you started to see higher turnover. ...There's just not a lot of applicants coming so we are trying to be proactive and pull people towards us rather than waiting for them to come."

Valleywise Health Medical Center nurses caring for COVID-19 patients during a spike of the pandemic in Arizona.

While it's true that a nursing shortfall is affecting all areas of health care, the need for psychiatric nurses is particularly severe, Stotler said.

Valleywise, which operates three behavioral health hospitals, has regularly been closing 80 to 100 of its 433 total inpatient psychiatric beds because of inadequate staffing, Stotler said.

Last week was an even higher number, with 118 of the 433 Valleywise beds closed, which amounted to five units and more than one quarter of the health system's total number of inpatient psychiatric beds, leaders said.

Health systems across the U.S., including Arizona, have had trouble hiring and keeping nurses in general since the pandemic. Attention and solutions to that problem have focused on providing critical care nurses to the medical, non-psychiatric areas of the hospital that treat COVID-19 patients, as well as patients with other physical ailments.

Valleywise still has the reinforcement of travel and per diem nurses for acute medical (non-psychiatric) care. Such supplemental staffing hasn't been as easy to procure on the behavioral health side, she said.

The Valleywise psychiatric beds are for people in serious mental health crises — most of the patients are there because a loved one, a medical provider or a court believes they are a danger to themselves or others.

Valleywise beds are closed at a time when mental health needs are rising

Having psychiatric patients spending prolonged periods in emergency departments is a stressor on ER care because ER techs, nurses or nursing assistants have to often watch the patients and cannot do anything else, LoVecchio said.

"Many of these patients are on direct observation for fear of self-harm," he said.

Exacerbating the situation is what providers say is higher-than-usual demand for psychiatric care that began during the COVID-19 pandemic and has persisted. 

At the same time that mental health needs have increased, more behavioral health nurses have been leaving either for retirement or other jobs, said Katee Sharp, nurse manager at Valleywise Behavioral Health - Mesa, which has 127 inpatient psychiatric beds, including a 12-bed unit for adolescents ages 12 to 17.

The adolescent unit, which used to see seasonal drops and surges, has been operating at a consistently high level of occupancy since the pandemic, Valleywise officials said.

Phoenix-based Valleywise Health, a public health system that serves a large percentage of vulnerable patients, has long been accustomed to seeing high turnover rates for behavioral health technicians.

Not all nurses want to specialize in psychiatric care. Sharp recalls in her nursing school class of 60, just two went into psychiatric nursing. It's not as appealing as the emergency department or the neonatal intensive care unit, she said.

Still, Sharp, who has been at Valleywise for six years, said she's never seen struggles to hire psychiatric nurses like what's happening now. 

"It's very sad to see that our numbers are dwindling because the staff here truly love their jobs. They love who they work with. They love the patients, they love the work. This is where they want to be," she said. "It's all the other factors that kind of get in the way."

Those factors include the fact that by law employees must contribute 12% of their earnings to the state's retirement system through their paycheck, which makes take-home pay lower than some employees would like.

In order to help solve the problem, Valleywise developed an internal "Behavioral Health Nurse Externship" program during the pandemic that helps existing staff to further their education by providing them with clinical experience in caring for behavioral health patients while they go to nursing school.

In exchange, the employees make a two-year commitment to work as behavioral health nurses for Valleywise after graduation. So far two Valleywise employees — a former  legal assistant and an employee who spent 10 years as a behavioral health technician —  have completed the externship and five others are in the program.

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Steward Health has a $7,500 sign-on bonus for behavioral health nurses 

Valleywise needs to hire at least 40 more behavioral health registered nurses to be fully staffed, Stotler said. The health system is also looking to hire at least 50 behavioral health technicians, she said.

It's not just Valleywise Health that needs more behavioral health nurses. Phoenix-based Banner Health, the Arizona State Hospital and Steward Health's Arizona hospitals need more behavioral health nurses as well.

Phoenix-based non-profit Banner Health, which has 354 inpatient psychiatric beds in Arizona, as of May 13 had about 36 openings for behavioral health nurses, spokesperson David Lozano wrote in a May 13 email. Banner has 288 inpatient psychiatric beds in the Valley and 66 in Tucson.

While its psychiatric beds are not technically closed, there are challenges admitting patients to some of Banner Health's inpatient behavioral health facilities "due to current staffing issues," Lozano wrote.

Patients at Valleywise Health Behavioral Health Center can stay  with a roommate or have a room to themselves.

"At the present time, we are staffed to care for about 215 patients in the Valley out of a possible 288 beds," he wrote.

The 390-bed Arizona State Hospital in Phoenix had 26 vacant psychiatric nursing jobs as of May 10, state health officials wrote in an email, but the shortfall has not resulted in any bed closures.

St. Luke’s Behavioral Health Center in Phoenix, operated by Dallas-based for-profit Steward Health, has 35 immediate full-time and part-time positions open for for nurses, and is offering a sign-on bonus of $7,500 when hiring requirements are met,company officials wrote in a May 20 email.

St. Luke’s has 127 inpatient beds for ages five to adult. Seward Health has 20 additional behavioral health beds at Mountain Vista Medical Center at the Generations Program unit in Mesa that specializes in ages 55 and up. 

The company recently partnered with a recruitment company to bolster efforts to find more nurses, chief nursing officer Donna Berry said in an emailed statement.

The company recently implemented a schedule to provide nurses with a better work-life balance by giving them two weekends off per month and in February, Steward gave its nurses a salary increase that the company believes "mirrors or supersedes our competitors," Berry said.

"Our nursing workforce was substantially impacted by the pandemic. With the nursing shortage, there has been aggressive recruitment from our competitors on all fronts to include lucrative compensation packages. Travel assignments have been very attractive to nurses in our area, with options to work in Hawaii, California and more."

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The pandemic heightened frustrations for some psychiatric patients

The pandemic heightened frustrations for some inpatient psychiatric patients and for staff, too, Sharp said.

Because most of the patients in Sharp's facility are not there voluntarily, there's always some frustration. But the pandemic exacerbated the situation for some patients who didn't believe COVID-19 was real, who fought staff who told them they'd tested positive, and who suffered when they had to quarantine in their rooms, she said.

Others were confused by health care workers donning full personal protective equipment, including masks and face shields, she said. With face masks, patients could not always discern whether it was a health care worker speaking, or whether it was internal voices they were hearing.

A COVID-19 patient is tended to In one of the COVID-19 units at Valleywise Health Medical Center in Phoenix on Jan. 14, 2021. Much of the hospital has been converted to handle COVID-19 patients and they like many other hospitals throughout Maricopa County are at or near capacity.

There's been an "ongoing, longstanding problem" where patients spend prolonged periods in emergency rooms waiting for an inpatient psychiatric bed and the pandemic is one of several factors that made it worse, according to Jim Dunn, executive director of NAMI Arizona. NAMI stands for the National Alliance on Mental Illness.

Other aggravating factors include a  preexisting global health care worker shortage, partisan politics and lack of proactive big picture assessment and treatment of financial and staffing realities, he wrote in an email.

"And of course further compounded by travel, distance, poverty, and geography in our rural communities," he wrote.

The mental health workforce in Arizona was not keeping pace with demand even before COVID-19 pandemic hit. A November 2020 report from the University of Arizona's Center for Rural Health found that 40% of Arizonans live in an area where there's a shortage of mental health professionals, and that 61% of Arizona adults experience mental illness but do not receive treatment.

This report found 779 psychiatrists practicing in Arizona representing 4.6% of the licensed physicians in Arizona, which is a a ratio of 11.4 psychiatrists per 100,000 Arizonans and is lower than the national average.

The report also found that five of Arizona’s 15 counties — Gila, Graham, Greenlee, La Paz and Santa Cruz — did not have a psychiatrist at all.

Report: AZ mental health workforce supply is one of the worst in the U.S.

"The State of Mental Health America" 2022 report, released by the non-profit national group Mental Health America, ranks Arizona 49th out of 50 states and the District of Columbia in a best to worst overall ranking. Only Idaho and Nevada rank lower.

The overall ranking takes into account nine different measures of mental health, including the percentage of adults with serious thoughts of suicide, adults with mental illness who did not receive treatment, and mental health workforce availability.

The report, which is based on pre-pandemic data from 2018 and 2019, ranked Arizona's mental health workforce availability as 48th out of 50 states and the District of Columbia. Only West Virginia, Texas and Alabama ranked lower.

"One of the primary barriers to establishing a robust, diverse mental health workforce is low provider reimbursement," the report says.

"Payment affects the diversity of the workforce, especially in a field that requires high levels of education and certification. Provider reimbursement should take into account workforce shortages and promote equity in access."

Sharp knows psychiatric nurses who returned to other specialties during the pandemic, including to acute bedside nursing  and never returned to behavioral health.

Others took early retirement, some chose to further their education, and some have since left for higher paying jobs in less stressful areas of behavioral health nursing, like at privately-owned facilities where patients have not been court-ordered into care, she said.

 It's true the job at Valleywise can be difficult, but it is also rewarding, Sharp emphasized. She's watched patients with severe, debilitating mental illnesses get treatment and get better.

"I've seen some cases of patients that are in so much distress and they are so ill and dangerous and once we get them on the right meds you would never guess that they were ever in that state of mind," she said.

"It's those cases that really kind of fuel us. ... They are at their own baseline where they can still live a successful life.

"Those are the cases that a lot of people in the world might have just looked away from — the homeless man on the street, or a woman running around in traffic — those are the people we are here to help and help them get better."

Reach the reporter at Stephanie.Innes@gannett.com or at 602-444-8369. Follow her on Twitter @stephanieinnes