Excellent article. The American Medical Association tells its members the true story....
American Medical Association
HEALTH & SCIENCE http://www.ama-assn.org/sci-pubs/amn...1/hlsa0618.htm
Where's the nurse? Staffs stretched too thin
As nursing shortages reach crisis proportions, both physicians and patients suffer the scarcity. Who will answer the call? The solution won't be easy.
By Stephanie Stapleton, AMNews staff. June 18, 2001.
"I have spent many afternoons with nurses crying on my shoulder, only to have them leave the next day. My day takes twice as long, without enough nurses to cover the procedures that a tech can't do. The nurses are so tired and overworked, you can see it in their bodies, their eyes, their attitude. It makes working at the hospital a dread."
-- Katrina Miller, MD
These words are from a second-year family medicine resident at the University of California, Los Angeles. But her experiences are not uncommon.
Physicians are increasingly feeling the strain of hospital nursing staffs that are stretched too thin.
Although the nursing work force has always been cyclical -- reflecting ebbs and flows in the economy and the needs of the health care delivery system -- the present circumstance is considered by many to be different.
"On one hand, the current situation is a typical nursing shortage in that there are not enough nurses to fill all the positions out there," said Patricia Underwood, RN, PhD, first vice president of the American Nurses Assn. But this particular one is also more intense than those in the past, she said.
For starters, trends indicate that growing numbers of licensed registered nurses are opting not to work in the profession. About 494,000 RNs did not use their licenses last year. This number increased from 443,000 in 1996 and 387,000 in 1992, according to the Health Resources and Services Administration. In addition, the average age of those who stay is getting older.
494,000 licensed RNs did not work as nurses in the year 2000.
The Journal of the American Medical Association published a study June 14, 2000, predicting that, because of the impending retirement of the largest age cohort of nurses -- those currently in their 50s and 60s -- the work force will be nearly 20% below projected needs by 2020.
Meanwhile, the number of new nurses entering training programs and the nursing field is getting smaller. These factors are converging just as hospital patients are typically getting sicker and need more care. The combined effect could create a crisis as baby boomers age. But already, the shortage's impact is being felt, especially at hospitals.
The nursing shortage is quite real here. In our town we need 21 RNs to staff our 37-bed hospital, day and night, year-round. We only have 11. Registry nurses, at exactly twice the going salary, make up seven more. We are still three short. We experience L & D closures and total admission closures more than once a week.
-- Ken Ogilvie, MD, an Arizona-based ob-gyn
These kinds of staffing difficulties are increasingly prevalent across the country.
"It's a constant struggle," said Lawrence Schecter, MD, medical director of Santa Monica-UCLA Medical Center. He views the problem from two perspectives -- as an administrator and as a general surgeon. In his own facility, nurse staffing levels are a constant question. "Every night I go to our nursing office and ask how we are for tomorrow," he said.
A key factor contributing to the shortfall is that hospitals and other acute care facilities have in the past decade faced reduced reimbursement rates and pressure from managed care companies. This has led to cuts in operating budgets. Because nurse salaries represent, on average, about 20% of such costs, they have been high on the list of targets.
"There is cutting the fat and then there is cutting the bone and muscle," said Todd Taylor, MD, the Arizona College of Emergency Physicians' vice president for public affairs. "Nurses are the bone and muscle. When they are cut, the hospital is starting to implode."
At 20% of hospitals' operating budgets, nurses salaries have been targeted as a cost-cutting measure.
The number of patients assigned to nurses, for instance, is on the rise. Nurses report sometimes having to care for 10 or more medical or post-surgical patients during a day shift. And, while patient care responsibilities are intensifying, shifts are getting longer. In addition, mandatory overtime has become common to fill staffing gaps. The work is hard and physical. The paperwork burden continues to grow. The result: Burnout is prevalent and turnover is at record highs.
"Nurses work hard and get beaten up badly. It's probably why so many leave," said UCLA's Dr. Schecter.
There is also more and more awareness about the risks involved in hospital work -- from needle sticks to ergonomic challenges, Dr. Underwood explained. Concerns about threats from patients and patient families are also becoming more common. "Right now, a lot of things happen that call safety and quality into question," she said.
But even as many nurses opt to leave their full-time hospital posts, the facilities have to have adequate staff. As a result, they turn to what some physicians say is a burgeoning industry -- agency or registry nurses.
In our medicine/surgical ICU we have only a bare skeleton of staff nurses with experience. For an 18-bed unit we have seven full-time nurses. The rest are "agency nurses." This has affected the quality of care, and the morale is so low. The agency nurses are part-timers of marginal quality who make more money than do the full-time nurses, because the agency can get more money. They in essence hold the hospital hostage. At the present we are limping along, but I don't know how this will be resolved in the long run.
-- Richard Hoefer, DO, a surgical oncologist in Newport News, Va.
Nurse staffing agencies allow their nurses to function as free agents -- sending them out to staff health care facilities on an as-needed basis while giving them more control over their schedules and, often, more money.
"I've seen the entire emergency staff evaporate," Dr. Taylor said. "About a half of ED nurses on a regular basis are some type of traveler." Of the 12 nurses who work in his hospital's emergency department, only the three supervisory positions are filled by regular staff at times.
"It is disheartening. It causes despair," he said. "You don't have the core group. Just rent-a-nurse." Even though these temporary staffers may be clinically competent, they often don't know hospital policies or procedures. "They don't even know where the bathrooms are," he added. "It's not efficient."
George M. Boyer, MD, chair of the medical staff quality committee at Baltimore's Mercy Medical Center, said that like most, his hospital "absolutely" suffers from chronic staffing problems.
"For our own institution, it is not causing a crisis in actual care, but it is getting close nationwide," said Dr. Boyer, also an assistant professor of medicine at the University of Maryland, Baltimore. "There is no quick answer."
Many times, for instance, when facilities are on red or yellow alert, it is not because all the beds are full, he said. It is because all the beds that can be staffed are full.
I work in an emergency department where, on occasion, we have to hold patients until an inpatient bed becomes available, sometimes the next day. I've had up to half my ED beds filled with inpatients. This greatly slows down the ED care and ties up my ED nurses with floor duties. I know that the patients are uncomfortable spending hours lying on ED cots, in addition to not being the ideal place to recover. I know that this situation is not unique to our hospital.
-- A physician who opted not to provide his or her name
Dr. Taylor said the effects felt in emergency departments might be among the most visible. When the hospital is unable to staff surgical and other beds, the ED picks up the slack, he said. "We've been down to one-third capacity because we're holding hospital patients in the emergency department."
But the pressures are evident throughout facilities.
"There are times when we have scheduled procedure -- we have the rooms and the necessary equipment available," said Dr. Boyer, who practices pulmonary and critical care medicine. "But we have no nurses to staff them."
And in the end, it becomes an issue of quality. "There may be space at hospitals, but if you don't have a nurse, who is going to take care of you?" asked Dr. Taylor. "We've reached a point where families need to sit with the patients to make sure things are taken care of."
This kind of realization has added a new imperative to efforts to address the current shortage in a way that will prepare the health care system for the even greater demands of patient care in the future.
According to Pam Thompson, RN, executive director of the American Organization for Nurse Executives, the shortage should be framed as a larger systemic issue because of the complexities it involves. If a resolution is to be reached, it will require change at multiple levels -- including nursing education, the work environment, regulations, laws, and financing. "There is no single bullet, not one simple thing we can do to fix this," Thompson said.
Legislative proposals to create scholarships
to attract more young people to nursing, for example, will not correct the problem without increased financing for nurse training programs and investments to maintain an adequate supply of nurse faculty.
Finally, many agree that -- even with higher pay and more incentives -- the WORK ENVIRONMENT MUST CHANGE if nurses are to be recruited and retained. Ample data show that a big factor in retention of nurses is the interaction with physicians, Thompson said. "If it is good, nurses stay and patient outcomes are better."
"I'd love to tell you that it wasn't true, but it seems that nurses' treatment by physicians is always on the list of reasons for nurse dissatisfaction," Dr. Boyer agreed.
"Some [doctors] are hard to work with, but hopefully, as a group, we're not all difficult," he added. "Physicians have to learn to work as part of a team. The days in which a doctor would walk into a room and the nurse would stand up to give him her chair are over."
Causes for concern:
The number of nurses leaving the profession, the graying of those now in the field and the dwindling number in training fuel concerns about a shortage.
In 1980, 52.9% of RNs were younger than 40; by 2000, only 31.7% were under 40.
The U.S. population increased 13.7% between 1990 and 2000. The rate of nurses entering the work force increased just 4.1% between 1996 and 2000, down from 14.2% between 1992 and 1996.
There are nearly 2.7 million RNs in the United States. More than 18% do not work in nursing.
In a recent American Nurses Assn. survey, 75% said they feel the quality of nursing has declined during the past two years.
Forty percent said they would not feel comfortable having a family member cared for where they work.
Source: American Nurses Assn.; Health Resources and Services Administration's 2000 National Sample Survey of Registered Nurses, February
The following forces are factors in burnout, job dissatisfaction and the growing nurse shortage:
The burden of care for nurses, patients and families has increased since 1990.
Pressures on families are particularly severe when patients are sent home after a brief stay or have received outpatient care for problems that were formerly dealt with in hospitals by nurses.
There is evidence that nurses and families are very concerned about the erosion of care and are fearful about hospital safety.
Nurses report increasing dissatisfaction with their work in hospitals that have cut staff, require frequent overtime and replace nurses with assistants.
Source: "When Care Becomes a Burden: Diminishing Access to Adequate Nursing," Milbank Memorial Fund
A survey published in the May/June issue of Health Affairs contacted nurses in five countries: the United States, Canada, England, Scotland and Germany. It explores nurses' attitudes about their jobs and the state of hospital care.
Job dissatisfaction, burnout, and intent to leave:
In the United States, 41% of hospital nurses reported job dissatisfaction. Except for Germany, nurses in the other countries expressed dissatisfaction at rates between 30% and 40%.
More than two in 10 American nurses and 33% or those younger than 30 plan to leave their jobs in the next two years.
Work climate in hospitals:
More than one-third of nurses surveyed reported that there are enough registered nurses to provide high-quality care.
Among American nurses, 82% reported an increase in the number of patients assigned to them in the past year.
Fewer than half overall reported that management was responsive to concerns.
Quality of care:
In the United States and Canada, only about one-third of nurses surveyed were confident that their patients were adequately prepared to manage at home after discharge.
Nearly half of American (44.8%) and Canadian (44.6%) nurses said the quality of patient care in their institutions had deteriorated in the past year. This deterioration was less commonly reported in European countries.
Source: Health Affairs, May/June
Milbank Memorial Fund Milbank Memorial Fund report, "When Care Becomes a Burden: Diminishing Access to Adequate Nursing" (http://www.milbank.org/010216fagin.html)
Health Affairs article, "Nurses' Reports on Hospital Care in Five Countries," May/June (vol. 20, number 3) (http://www.healthaffairs.org/archives_library.htm)
Bureau of Health Professions, to obtain the 2000 National Sample Survey of Registered Nurses, preliminary findings, February (http://bhpr.hrsa.gov/)
JAMA abstract, "Implications of an Aging Registered Nurse Workforce," June 14, 2000 (vol. 283, number 22) (http://jama.ama-assn.org/issues/v283n22/abs/joc91904.html)
The email address of the AMA reporter of this article can be found at http://www.ama-assn.org/public/journ...s/amnstaff.htm
American Medical News Staff List.