Nursing Shortage Is Raising Worries on Patients' Care
By MILT FREUDENHEIM and LINDA VILLAROSA
Nurses, hospital executives and health care experts say that a shortage of
nurses across the country is becoming so severe that it threatens patient
The vacancy rate for nursing positions at 73 hospitals in New York,
Westchester and Long Island is averaging 8 percent, up sharply from 5.5
percent in 1999, the Greater New York Hospital Association said last week.
The shortage is even worse in California: vacancies in the 470 hospitals
there averaged 20 percent in December, according to the California
At Westchester Medical Center in Valhalla, N.Y., the largest and busiest
hospital between New York City and Albany, more than 25 percent of the
positions for operating-room nurses were unfilled as of late last year.
Surgeries backed up and some were postponed, sometimes for several days.
Since Jan. 1, the hospital has filled about half the openings by
recruiting from other parts of the hospital, bringing in recent nursing
school graduates, and hiring. But Ellen Widera, a longtime nurse at
Westchester Medical, says it often takes months for new people to learn
the operating room routine. "It is stressful having to do their job and
your job, sometimes at the same time," she said. "You're up to your elbows
in hepatitis blood and AIDS blood. It's dangerous." The hospital, which
currently employs 1,500 nurses, had 190 openings for nurses on March 1, up
from 144 only last November.
Because of short staffing, many nurses say they are forced to stay on the
job when they are exhausted after a 12-hour shift. "It really ought to be
illegal for nurses to work double shifts," said Lucian Leape, an expert on
patient safety at the Harvard School of Public Health. "You don't allow
airline hostesses to work more than eight hours. Why would anybody think
nurses are less important?"
Hospital administrators and nurses expect the shortage to worsen.
Enrollment in nursing programs
is declining even as the population ages.
The average age of nurses is rising.
And some nurses are becoming bitter. The shortage means those still on the
job are responsible for more patients and those patients are often
sicker, thanks to managed care requirements that more care take place
Patients already find it harder to get a nurse to respond promptly when
they call for help. Eighteen percent of consumers rated their last
hospital stay fair or poor in a survey reported in 1999 by Karen Donelan
and Robert J. Blendon of the Harvard School of Public Health.
Frustrated, growing numbers of nurses are joining unions that threaten and
sometimes call work stoppages as their militancy increases. Working
conditions in hospitals were a central issue in at least 36 strikes by
nurses in the last two years, including three in 1999 by the New York
State Nurses Association. Many nurses are also pressing for state and
federal staffing rules.
Hospital executives say they would hire more nurses if they could find
them, but nurses say working conditions in hospitals are driving many of
them out of the profession.
"The nursing shortage is one of the dominant issues in health care today,"
said Peter Buerhaus, associate dean at the Vanderbilt University School of
Nursing in Nashville, whose findings were published in The Journal of the
American Medical Association last year. "In some cases the problem is so
severe that hospitals have had to shut down nursing floors and cancel
surgeries. This crisis has the potential to create a disaster scenario in
terms of the quality of care."
In many hospitals, nurses say they are required to take care of 10 or more
medical and postsurgical patients at a time, and those patients are often
seriously ill. They complain of injured backs after lifting heavy patients
and of risky accidents with contaminated needles.
"In the past year, the number of patients per nurse has increased and
workloads have increased," said Relie Dema-Ala, a nurse at Glendale
Memorial Hospital in Glendale, Calif. "The work is tremendously hard and
stressful," she said. On Wednesday, nurses at Glendale Memorial voted 167
to 136 to affiliate with the California Nurses Association.
At the same time, adjusted for inflation, average nurse salaries have
hardly changed since 1992, according to a report in February by the Bureau
of Health Professions in the federal Department of Health and Human
Services. The average salary of a full-time registered nurse was $46,782
last year, it said. Hospitals, squeezed by managed care, have generally
kept their salaries in check.
There were 2.2 million registered nurses working in health care last year,
according to the Bureau of Health Professions report, but 494,000 nurses
were not using their licenses, compared with 443,000 in 1996 and 387,000
"We've burned out an entire generation of care givers," said Jeff
Goldsmith, president of Health Futures, a hospital consulting firm.
Hospital executives say they are trying hard to recruit more nurses,
offering perks like health club and spa memberships, "night out" baby-
sitting for nurses' children and even vacations in Hawaii.
The Tenet Healthcare Corporation, the second-largest for-profit hospital
chain, is experimenting with providing cordless phones for nurses to use
at work, scholarships
for their children and discount purchasing programs.
Tenet would like to hire 3,000 more nurses for its 110 hospitals, said
Alan R. Ewalt, executive vice president for human resources.
But recruiting has been only moderately successful, and demand for bedside
nurses has outpaced additions to the work force. There are now 100,000
openings for registered nurses, according to Joseph Boshart, president of
Cross Country Travcorps, one of the largest temporary nurse staffing
The American Association of Colleges of Nursing in Washington said that
enrollment of nursing students in entry-level bachelor's degree programs
fell by 2.1 percent in the fall of 2000, the sixth annual drop. The lower
enrollments mean the average age of nurses is rising. The health
professions bureau says the average age of the 2.6 million registered
nurses is 45.2 years and rising. In 1980, 52 percent were estimated to be
under 40, compared with 31.7 percent currently. And only 18.3 percent of
nurses are under 35, compared with 40.5 percent 20 years ago.
Older nurses are often less willing to take on more patients and mandatory
overtime. "Some nurses are just unable physically to handle the heavy
demands of patients," said Linda Aiken, director of the Center for Health
Outcomes and Policy at the University of Pennsylvania School of Nursing.
In a recent survey in Pennsylvania, 41 percent of the 14,000 nurses
responding said they were dissatisfied with their job, and 22 percent were
planning to quit within the next year.
P. K. Scheerle, a nurse who is now chief executive of American Nursing
Services, a temporary staffing agency, said: "When I was a young nurse I
used to be able to work 12-hour shifts, but now that I'm in my 40's and
with children at home, if I worked that kind of shift, muscling eight
patients, I'd be totally exhausted."
About 350,000 of the 2.2 million nurses working in health care are union
members today, up from 300,000 in 1995, according to the Census Bureau.
And the nurses unions are becoming more active: the Massachusetts Nurses
Association voted to leave the American Nurses Association on March 24,
saying the national group was too moderate. The California Nurses
Association, which became independent in 1995, announced an alliance last
month with the United Steelworkers of America, which already represents
other employees in a number of hospitals.
"Wages are always an issue, but they are not the principal issue," said
Susan Bianchi-Sand, director of United American Nurses, the labor union
affiliate of the American Nurses Association. "Safe staffing and the
quality of patient care are higher priorities."
Nurses are getting increasing attention from legislators. In Washington,
they have been pressing, with bipartisan support, for increased federal
subsidies for nursing education. And last month, Representatives Tom
Lantos, Democrat of California, and James P. McGovern, Democrat of
Massachusetts, introduced legislation that would ban mandatory overtime
But last week, President Bush proposed to cut spending for medical
education by 60 percent, to $140 million from $353 million.
California, Kentucky and Virginia are setting standards for appropriate
staffing. Legislators have introduced less specific proposals in New York,
Ohio and Oregon.
In addition, 15 states, including New York, Connecticut, California and
Illinois, are weighing bills that would prohibit forced overtime for
nurses. Maine passed an overtime measure, and New Jersey is drafting
"Mandatory overtime is a huge issue," said Stephanie Reed, a lobbyist in
Washington for the American Nurses Association. "Nurses have to work
overtime when they are exhausted. The nurses have a tremendous fear of
making mistakes. It's a patient safety issue."
Copyright 2001 The New York Times Company