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Building it was the easy part.

Now that Baton Rouge General’s Bluebonnet expansion is finished, staffing it fully is proving a challenge. An acute shortage of nurses and certain other high-demand clinical positions has spurred the General to any number of experimental and innovative tactics to attract the necessary staff to run the place.

Not growing wasn’t much of an option: At the Bluebonnet campus pre-expansion, the number of patients sometimes exceeded the number of beds, which stood at 105. Post-expansion, it’s 203. Ideally, a hospital is never 100% full, but hovers around 80%. Bluebonnet was way past the comfort level. Patients were being held in surgery and the emergency room until regular beds could be found. It was crowded.

While the expansion is open, it’s not completely online. When everything is up to speed and every new job has been filled, the General will have hired between 400 and 500 people, though it’s not going to happen tomorrow.

“We’re slowly creeping up,” the General’s Vice President of Human Resources and Development Paul Douglas says. “Right now because of the (patient) demand, we’re still trying to open units, trying to bring people on, but doing it in a controlled manner. You have the right physicians, the right staff, the right processes.”

The General has more than 600 nurses at its Bluebonnet and Mid City campuses. About 15 are contract nurses, so-called travelers who flit from hospital to hospital through nursing agencies and are compensated extremely well. The General also has its own in-house nursing contracts. They’re highly paid but, unlike travelers, stay in Baton Rouge.

“Even though we have a good pipeline of new graduates and we’re doing well in the local nursing market, there aren’t enough nurses for the next wave of unit openings, and I need a few more beds at Mid City.”

The shortage is spurring experimentation and innovation in trying to attract enough people. In short, Douglas is pulling out all the stops, but stopping short of settling for just anybody. Not that the hospital was taken unawares by the staffing difficulties that would inevitably result from the expansion—efforts to fill the gap started early on.

One thing administrators have done to find enough bodies to staff the next wave of unit openings: a regional campaign in target markets that offers to pay for experienced nurses to relocate to Baton Rouge and go to work for the General.

“The first Monday after that campaign, we had 62 phone calls,” Douglas says. “Now we’re doing the interviews. We measure that because we want to know, are we getting a return on this campaign?”

For the short term, Douglas needs 20 to 40 more nurses than he has right now—in addition to the new nursing graduates that have committed to the General. “Ultimately, when we finally have this thing fully rolled out, it will be 400 to 500 additional jobs.”

It would be a lot easier if the General and other hospitals could throw lots of money around. It is likely the staffing shortage would evaporate in short order under those conditions. But these are lean times for big, full-service medical institutions.

“It’s tough right now,” Douglas says. “I think an A-rated hospital right now is somewhere around a 3% margin. That’s not a good margin.”

Plus there’s a documented shortage nationwide of the kinds of front-line licensed clinical professionals the General and practically every other full-size hospital in the country are looking for. Nursing is the biggest category, but not the only one.

Getting X-ray techs is not hard. Getting advanced X-ray techs for MRI, CT, nuclear and tomography is. The General basically had to grow its own by cross-training and paying existing staff to do these jobs. This, despite the fact that the General started planning clinical recruitment for the expansion about four years ago and started actively recruiting three years ago.

“We knew we would have to increase the local supply of qualified nurses, so we increased the size of our nursing school,” Douglas says.

While there are plenty of great nursing schools in Louisiana, he says, there’s only so much clinical space for nursing students to get the hands-on aspect of their training.

“We made sure we opened ourselves to everyone for clinical space,” Douglas says. “If there’s a school and they need clinical space, we provide it.”

Baton Rouge Community College is trying to start a nursing program, though Douglas notes one of the biggest impediments is lack of clinical space for training. So the General offered itself to BRCC as its primary clinical site.

The hospital also started an intern program for junior and senior nursing students, who follow real nurses around during the summer to pick up skills and a paycheck. It helps them graduate and they’re more confident when they actually go to work, Douglas says.

Besides the internships, cross-training, retention and out-of-market recruiting, the General also recently rolled out a program that pays off students’ nursing school loans in exchange for an agreement to work there. The hospital has also been recruiting former employees, and surveys show 87% of them have a willingness to return to the General.

And then there’s all the money.

“You want to talk about money? We have done huge wage increases in every category across the board since Katrina,” Douglas says. “It’s been a huge money burn. Not only do we have annual pay raises, we’ve just done market raises. We’ve done a lot of things with pay.”

For instance, last year, when Our Lady of the Lake Regional Medical Center raised its nursing salaries, the General was forced to spend about $1.4 million to match it.

“It usually happens about new graduate time,” he says. “Everybody’s competing for new graduates. If they raise the price of a new graduate a dollar, then we have to match it. They went up a dollar. We went up a dollar.”

It could have been much worse if the state hadn’t already taken steps to deal with the nursing shortage.

Joe Ann Clark, executive director of the Louisiana State Nurses Association, says state leaders and legislators have done a good job addressing the problem through providing capitation funds that let nursing schools accept additional students. Also, to deal with a shortage of nursing faculty, the state provides a stipend for nurses to go back to school, get advanced degrees and teach.

“You have to have a master’s degree to teach and you have to have a master’s degree to be an advanced practicing nurse,” Clark says. “You can make close to double the salary as an advance practice nurse. That’s one of the reasons people don’t go into teaching.”

The shortage of faculty is especially troublesome as schools brace for a wave of faculty retirements. A seemingly obvious solution—increasing faculty pay—hasn’t gained traction. It’s not for lack of trying on the part of people like Clark, who’s been pushing for it to no avail.

“A lot of people say teaching nursing is easy,” Clark says. “Let me tell you, as one who has it done for many years, it’s not.”

KarenSue Zoeller, the Louisiana Hospital Association’s vice president for workforce development, says 70% of the state’s nursing faculty is at or very near retirement age. The various programs implemented in response to the nursing shortage have put hundreds of additional nursing students in the pipeline and created dozens of extra faculty, Zoeller says.

“It will not take care of the problem completely. It is actually just enough to meet current demand.”

The fact that nursing faculty pay remains far below that of faculty in fields like engineering or business—despite the chronic shortage—is a puzzler, Zoeller says.

“This is a discussion we have had over and over and over again,” she says. “The [Louisiana Board of] Regents tell us it’s not up to them to tell systems how to pay instructors. System presidents will say it’s not up to them, it’s up to the individual campus presidents. It’s a matter of campuses making a decision that nursing instructors are just as valuable as other instructors.”