The Nursing Squeeze
Nationwide Shortage Puts Hospital Patients at Higher Risk of Complications, Death
By Susan Jacoby
May 2003
Surviving the Nursing Shortage
America's hospitals are hurting for nurses--a fact of life, new studies warn, that may have deadly consequences for some of their patients.
Nationwide, more than 126,000 hospital nursing positions are unfilled (one of every eight), placing patients at a higher risk of severe complications and death after surgery.
What's more, the shortage is deepening just as 78 million aging baby boomers are beginning to place an already shaky health care system under even greater strains.
Some hospitals have responded by making patients wait longer for admission, postponing nonemergency surgeries or even shutting down emergency rooms. Most hospitals, though, make do with what they've got, even as medical research has established, for the first time, a clear link between nursing caseloads and the increased risk of death.
Two major government-financed studies published last year, for example, demonstrated that as patient-to-nurse ratios rise above 4 to 1, so do postoperative death rates.
"Patients have every reason to be worried," says Kathleen Ann Long, president of the American Association of Colleges of Nursing. "Now we have proof from research that people can actually die from lack of nursing care--something nurses have always known. This should be a wake-up call to make the nursing shortage a public priority."
Experts say that the growing shortage of nurses has especially critical implications for older patients.
"The older and sicker the patients are, the more important nursing issues become," says Mathy Mezey, director of the John A. Hartford Foundation Institute for Geriatric Nursing at New York University.
Mezey points out that tired and overextended nurses "are less likely to notice the little signs--the soft early cough that can turn into pneumonia, for instance--that could literally make the difference between life and death."
THE BIG PICTURE
A study published in the Journal of the American Medical Association last year found a direct correlation between patient-to-nurse ratios and patient mortality rates. In reviewing the experiences of more than 232,000 surgical patients at 168 hospitals, researchers from the University of Pennsylvania concluded that a patient's overall risk of death rose roughly 7 percent for each additional patient above four a nurse was expected to tend. So did the risk of death from "failure to rescue"--not being saved from complications after surgery.
Researchers from the Harvard School of Public Health undertook an even broader study, publishing their findings last year in the New England Journal of Medicine. Based on a review of more than 6 million patients, they concluded that patients in hospitals with lower numbers of registered nurses were more likely to suffer from such complications as urinary tract infections and pneumonia and more likely to die from such treatable conditions as gastrointestinal bleeding.
There are, of course, the stories of patients calling hospital switchboards, or even 911, because no one would answer their call bells. But patients also feel the effects of nursing shortages in myriad smaller ways, from longer waits in emergency rooms for those who need to be admitted to the hospital (because there aren't enough nurses on the regular floors) to cancellation of elective surgeries (because there aren't enough operating room nurses).
NURSES KEY SOURCES OF CARE
No one disputes the notion that nurses are a key source of care and support for patients at the most vulnerable points in their lives. Sara Jonas, 54, tells the story of a nurse at a hospital in Lansing, Mich., who took her aside to tell her that her 81-year-old mother seemed depressed after an invasive radiological procedure to drain a lung abscess.
"She recommended that I make Mom get out of bed and walk even though she didn't want to," Jonas told the AARP Bulletin. "I resisted at first, saying my mom was too weak, but the nurse pointed out to me that one reason for her depression was the weakness itself. I took her advice, and so did my mother, and she was well enough to go home within the week. I credit that nurse for seeing something my mom's doctor and family didn't see."
Marilyn P. Chow, a registered nurse who's vice president of patient care services for the California division of Kaiser Permanente, says that such "hands on, eyes on" nursing care is the reason why studies show a lower post-surgical death rate when nurses have smaller patient loads.
MORE PATIENTS, FEWER NURSES
The nursing shortage--some call it a crisis--won't be easy to fix because its causes are complex and intertwined. Among them:
Fewer women are becoming nurses. Many young women who used to become nurses are now becoming doctors or finding work in other fields once largely closed to women. Nationwide, only 5.4 percent of nurses are men.
Nursing has high burnout and dropout rates. Nearly 20 percent of all licensed registered nurses have left active nursing. For nurses trying to combine working and raising a family, the widespread hospital practice of mandatory overtime imposes a particular burden.
Nurses have lost ground in cost-cutting initiatives. Reduced reimbursements from managed care companies have led many hospitals to cut costs by eliminating support staff jobs--placing extra burdens on an already overworked nursing staff. In some hospitals, nurses are expected to pitch in and take up the slack for everyone from clerical workers to custodians.
Nursing schools aren't teaching and training enough new nurses. In 2000, the nation's nursing schools--partly because of a shortage of faculty and classroom space--turned away nearly 5,900 qualified applicants. And while enrollment in four-year college programs for nurses grew by 8 percent in 2002-03--the first such increase in recent years--there are still 11,500 fewer students in college nursing programs than there were in 1995.
Indeed, the labor shortage in the nursing profession seems likely to intensify in the years ahead.
Unless the current exodus from the nursing profession is stemmed, the Joint Commission on Accreditation of Healthcare Organizations estimated last year the number of hospital vacancies for nurses will rise to more than 400,000 by 2020, leaving nearly one in five positions unfilled.
More Info on the Nursing Shortage
The American Association of Colleges of Nursing (AACN) provides a Nursing Shortage Resource Web Link with fact sheets and reports on the crisis as well as information on the impact on patient care and suggested strategies for dealing with the crisis.
THE STATES TAKE AIM
Joan Bryant-Deschenes of Turner, Maine, worked in the health care field for 17 years before she was elected to the state House of Representatives, but even that didn't prepare her for the medical emergencies her husband faced last year.
Bryant-Deschenes says that she felt she had to stay by her husband's side when he was hospitalized for 26 days following multiple cardiac events that led to open-heart surgery.
"I found it absolutely necessary to be there," she told her colleagues during a legislative hearing in March of this year. "I felt that I had to advocate for my husband. He would have died if I had not been there to say, 'This man is too ill to go home.' "
Bryant-Deschenes says there weren't enough nurses on duty to properly care for her husband. She's not alone. In a recent public-opinion survey sponsored by the Harvard School of Public Health and the Henry J. Kaiser Family Foundation, 65 percent of those interviewed identified "not enough nurses in hospitals" as a "very important cause" of preventable medical errors.
Bryant-Deschenes, a Republican, has cosponsored legislation that would specify how many direct-care nurses hospitals in Maine must have for various types of care. "In the interest of patient safety," she says, "we need an appropriate level of skilled caregivers."
In 1999, California became the first state to mandate minimum nurse-to-patient ratios; the ratios, which are still being finalized and cover some 20 clinical units, will become effective next January.
Now, as the problem grows more acute, lawmakers in other states--among them Kentucky, Maine, Massachusetts, Missouri, Nevada, New Jersey, Oregon, Pennsylvania and Rhode Island--are considering similar legislation.
Hospital operators and administrators generally oppose such legislation, arguing that it deprives them of flexibility.
Nursing and health care organizations hoped for government help with the nursing shortage when President Bush, with considerable fanfare, signed the Nurse Reinvestment Act last year. In February Congress approved--and Bush signed--a law providing $20 million for nurse education programs that includes scholarships and continuing education grants. One aim: to encourage nurses to stick with the profession.
"As a society, for too long we've paid lip service to the value of nurses," says Long of the American Association of Colleges of Nursing. "Now it's time to put our money where our mouth is and treat nurses with the dignity they deserve."
Susan Jacoby is a freelance writer in New York City.
