Surviving the Nursing Shortage

  1. 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.
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  2. 20 Comments

  3. by   Agnus
    There is statistically a shortage. However, I have to question which came first the refusal to hire and pay a decient wage or the shortage.
    I suggest that if more nurse were hired and paid well the shortage would not exist.

    The truth is there are still stingy caps on the number of nurses that are allowed to work on a given unit in a given hospital. Even in this shortage employers limit the number of nurse they will utilize.

    Therefore I suggest that some of this "shortage" is artificial. There is an effort underway to recruite new blood.

    What do you think this will do to your ability to find work? What do you think this will do to wages?

    My contension is that this sort of thing goes in waves. At some point there will be an "excess" of nurses, as there is a lot of jumping on the band wagon to increase enrollment in schools.

    This excess will be just as artificial because. Employers wil still not hire more staff. And because the supply will be greater wages will suffer.

    I know plenty of nurses who refuse to work and I know plenty who cannot find work. NV has the fewest per capata. Yet the facilities and hospitals that are suffering are the worst when it comes to pay and treatment of nurses. Consequently many refuse to even apply to these facilities. We have the fewest per capata and when I go to NY (state) I hear the nurses just don't exist as they have no applicants at various facilities. Hmmm. Seems pay is pretty poor compared to NV and NV is Not caught up with CA by a long shot.

    Could poor pay be a factor, hmmmm? Of course it is.

    Not to mention respect, treatment etc. etc. etc. However, keep in mind that the more an employer pays some one the more respect it is likely they will be shown.

    Consider. Nurses are aging and been in the profession 20 and 30 years. They are getting paid more. It is cheaper to recurite and hire new inexperienced nurses, who justifiably do not earn as much. Look out with this influx of new blood as here comes the pink slip without gold watch not more experienced help.

    The excuse for not hiring experience will be "over qualified." Potential students have already started beating down the doors of schools who are not perpared to handle them. So now the blame falls on schools.

    Really! It would not be a national presedent for hospitals to sponsor nursing education. The fact is there has to my observation been no move in this direction at all. It would seem if there really was a shortage and hospitals really wanted nurses they would be moving in droves to sponser education.

    And their retention rates would not be so shameful.

    Guess which hospitals have the best retention. Geuss if these same hospitals have the lowest shortage, and guess how easily they recurite.

    Check the record those hospitals who have figured out how to keep nurses also have the most nurses per patient and have the easiest time recuriting.
    Last edit by Agnus on Jun 12, '03
  4. by   roxannekkb
    This is a great link about the so-called nursing shortage. There isn't one--just a shortage of places where nurses are willing to work.

    http://216.239.41.100/search?q=cache...hl=en&ie=UTF-8
  5. by   Euskadi1946
    There is not a nursing shortage, just nurses who are burned out from working in hospitals with staffing shortages because those hospitals are to cheap to hire a decent amount of nurses. How can you take care of 3 fresh cesarean sections, 3 fresh normal vaginal deliveries, and a 22 wk pregnant post op appy with v/s q 15 min x 4, v/s q 30 min x 4, also needs fetal and uterine monitoring q 2 hours. Labor and delivery was full so this patient was admitted to the post partum unit from the PACU. I was able to care for this patient post op and did take her vital signs, but not according to the routine post op protocol. There were no urine hats on the floor so how was I supposed to record output??? This is the scenario I was a part of last Monday night and was fired for not recording all of the above on this patient. The biggest mistake I ever made was to go back to floor nursing after working as a case manager for a large insurance company. Now I will try to find another nursing job, but only in a clinic or a nursing office...I will never ever work on another nursing unit as long as the staffing is inadequate.....THAT IS WHY THERE IS A NURSING SHORTAGE PEOPLE!!!!!!!!!!!!!!!!!!!!!!
  6. by   funnygirl_rn
    Originally posted by CeCiRN
    There is not a nursing shortage, just nurses who are burned out from working in hospitals with staffing shortages because those hospitals are to cheap to hire a decent amount of nurses. How can you take care of 3 fresh cesarean sections, 3 fresh normal vaginal deliveries, and a 22 wk pregnant post op appy with v/s q 15 min x 4, v/s q 30 min x 4, also needs fetal and uterine monitoring q 2 hours. Labor and delivery was full so this patient was admitted to the post partum unit from the PACU. I was able to care for this patient post op and did take her vital signs, but not according to the routine post op protocol. There were no urine hats on the floor so how was I supposed to record output??? This is the scenario I was a part of last Monday night and was fired for not recording all of the above on this patient. The biggest mistake I ever made was to go back to floor nursing after working as a case manager for a large insurance company. Now I will try to find another nursing job, but only in a clinic or a nursing office...I will never ever work on another nursing unit as long as the staffing is inadequate.....THAT IS WHY THERE IS A NURSING SHORTAGE PEOPLE!!!!!!!!!!!!!!!!!!!!!!

    CeCiRN...sheeesh...no urine hats...you must have been working where I work...we were out of urinals on Thursday, called to six different floors before I got some & that took some time (since I was put on hold while someone went to rummage through supply)...then, I had to go get them!

    So sorry to hear that you got fired. Sounds like you really had a terrible shift! Could you possibly go back to doing case management work...or are you burned out with that? Many of my friends, myself included are looking into other aspects of nursing as well. Some of my friends have left nursing entirely...due to the inadequate staffing & all that BS. I agree 100% with you regarding the staffing situation...and yeah...I think the hospitals are too cheap to hire an ample amount of nurses.

    PM me if you feel like it or need to vent. I do wish the best for you. I am sure you can find a job in a clinic or doctor's office...seen plenty of help wanted ads in the paper. In the mean time, relax & try not to think about that hospital you left.

    Take care.
  7. by   funnygirl_rn
    Excellent post Agnus...thanks Roxanne for the link!
  8. by   fairyprincess2003
    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.

    This right here is the exact reason that I am already getting fed up with nursing, and will be applying to medical school this year. I just don't understand why nurses are expected to do EVERYTHING. I didn't spend 4 years in school to have to do housekeeping and secretarial work. It is just ridiculous. They want to know why people don't want to go into nursing, well until they stop making like a nurse should be doing everything for some strange reason people are not going to want to do it!
  9. by   Euskadi1946
    Thanks for your support. I had an interview at our local Health Dept and although it's a huge cut in pay, at least I won't be doing floor nursing anymore, plus the benefits with the county are so much better....
  10. by   Agnus
    Gee, I thought I was alone in my theory about this. We know why they expect everything of us. Because we do it all.

    I was a bit PO'd at a minister who is a former nurse of 30 years. We were talking about how everything is $$$ driven today more than in the past. Then she said somthing about the nurses being unwilling to do as much work and demanding more $$.

    Why shouldn't we? Why must we be martyrs? I am not suggesting that we should be gold diggers but this is not the convent. No one here took vows. I have a right to my own health, sanity and the right to a decent living for my family.

    Even though I did not become a nurse 30 years ago, I remember what it was like and what nursing was back then. I did go to nursing school back then and I have a sister >30yrs a nurse.

    Nursing school is nothing like it was then neither is nursing. Lets get real. We are better educated and consequently do more and carry a bigger and more important responsibility today.
    Compared to today things were simplistic. We have learned a lot along the way, and grown but the volume of work has increased with knowledge because we never let go of those things we out grew.
    Florence may have trimmed the wick of her lamp but I will be damned if I am expected to do that level of simplisitic work, albiet necessary, which has no relation to nursing and do everything else too.
    Florence, did not have monitors to interpet, did not have code in her vocabularly, did not have a clue about ascultation, never pushed labatolol, etc. etc. etc.
    We are still in the dark ages of nursing. All that has changed it the amount of knowledge we have.
  11. by   roxannekkb
    No, you are not alone in your theory. The trouble is, no one wants to hear it, not even other nurses. Just listen to some of the verbage coming from the mouths of our nursing "experts" and "leaders" who think that the nursing shortage is caused by the "myths" about nurses. Well, there are plenty of myths about nursing, but what is the reality? The Johnson & Johnson campaign is nothing but a PR attempt to put some gloss on the nursing profession, and the nursing brass think that's the way to solve the shortage.

    So, they think the public should learn the truth about nursing. How about a reality TV show, about nursing. We can replay some of the scenarios described by members on this board. That will surely entice students to change their majors and hop on board!

    The truth be known, most hospitals aren't interested in solving their shortage. It's too expensive. Why hire ancillary personnel if nurses will do the jobs? And why hire more nurses, if they can get unlicensed personnel to do the job. Or foreign nurses who they can hire at cut rate and work into an early grave. I've noticed that a number of hospitals now have fancy names for CNAs--caregiver associates, clinical partners, and so on. Is that to confuse patients, so that they think an RN is caring for them?

    Yes Angus, not only are we in the dark ages of nursing, I tend to think things have gotten even darker. At least in the good old days, a nurse's job was more defined and simpler, in terms of the type of work. Now nurses have to juggle between high tech procedures, sophisticated machinery, endless paperwork, janitorial work---at my last nursing job, nurses in my unit were still pullling the trash on night shift!
  12. by   pickledpepperRN
    http://www.revolutionmag.com/newrev4/dondrug.html

    Pharmaceutical industry mergers appear to be a primary cause of the explosive rise in prescription drug costsnand may be a key factor in influencing hospitals to reduce hospital nurse staffing levels.
    ---------------------

    http://www.revolutionmag.com/newrev2/engineering.html

    Patients are sicker than ever, and there are fewer RNs at the bedside.
    RNs struggle with higher nurse-to-patient ratios and higher acuity levels of patients.
    More likely, the industry shortage is a self-inflicted wound brought about by years of market- and industry-led
    restructuring programs that led to indiscriminate downsizing, increased patient complaints about the quality of
    care, deteriorating RN-to-patient ratios, and most critically, a marked loss of RN trust.

    Just as the industry has created this crisis, it can help to resolve it. The industry can do its part to alleviate the RN
    shortage by adopting in word and practice a few simple principles:

    * Value patients as human beings and not as "covered lives."
    * Rather than expending resources fighting RNs and patients on safe staffing ratios, use those resources to
    enhance the ratios. The market is not able to set ratios that are safe for patients or that will assure
    adequate numbers of RNs.
    * Trust in the professional judgment and skills of the bedside nurse to advocate for the patient.
    * Terminate all contracts with management consultant deskilling programs and invest those hundreds of
    millions into preventative care and improving nurse-to-patient ratios.
    * When RNs testify that many health care restructuring programs are a form of patient endangerment -
    listen.
    * Accept that a profession dominated by women can and should earn a living wage commensurate with
    skills and dedication.
    * Promote direct caregiver role models as opposed to nurse executive models. The archetypal nurse
    executive may appeal to an MBA student but is decidedly less appealing to those who value nursing as a
    noble and hands-on calling.
    * Adopt RN work schedules that allow RNs some semblance of a normal life.
    * Provide RNs with adequate retirement and health benefits.
    * Provide increased funding for RN scholarships.
    * Expand educational and training opportunities for generalist RNs to learn specialty skills, and for LPNs,
    LVNs and aides to become RNs.
    * Work with nursing unions on projects to develop new programs for the future of nursing.

    Most importantly, do whatever it takes to restore the traumatic loss of RN faith in the industry that they see as
    having forsaken both them and their patients in the pursuit of private wealth over and above public health.
    That trust must be earned. It cannot be purchased with sign-on bonuses and certainly not with broken promises.
    The path back to that lost trust will be difficult. Common decency, an industry reaffirmation of the centrality of
    patient health in its mission and a commitment to the nursing profession that has made the industry one of the
    wealthiest in the nation demand it.
  13. by   coconuthead7
    I do not believe there is a "Nurse" shortage. If anything there might be an "RN" shortage. And no, I do not wish to restart the RN vs LPN debate, but the next time you hear a report about the "nursing shortage" see if the report indicates RN, or all nurses.
    I also think the "shortage", intended or not, is the result of doing away with the 3 year, hospital based, Diploma RN.
    I have been an LPN for 23 years, working in ICU,SICU,ER,MICU., but even now there are quite a few hospitals where I can't even insert an NG tube as an LPN. When I started nursing, if you had been an LPN for 2 years, you could challange the RN boards. When that was DC'd, a major transitional avenue to filling RN positions that were vacated by attrition, was removed. I believe that the phasing out of the Diploma RN, and the transitional LPN to RN challenge, was nothing more than political posturing.
    As long as there is a "shortage", there is political power.
    I know. " If you want to practice as an RN, go to RN school". But by the same token, if you want to be a CRNA, NP, etc, should you be made to go to "MD" school?
    This is my first posting, and I do not want to be considered a rock thrower, but if there is a "shortage", first use ALL nurses to cure it, and bring back the means to do so.
  14. by   fairyprincess2003
    Angus I could not agree with you more, you read my mind,
    for the last poster..you see that is the problem. Nursing in general is pushing more education down our throats, and advanced skills, yet we are still expected to do everything from the ground up. We are expected to increase our skills and education, yet still be willing to handle every single duty and then some. Nursing will not get the respect until we are allowed to stirctly focus on the knowledge and skills we have, and not be expected to be the overall servants basically.

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