Health care: Many are using bonuses and other incentives to woo new workers, often to the dismay of veterans.
Los Angeles Times, April 21, 2002
By RONALD D. WHITE, TIMES STAFF WRITER
Ronan Umali is the kind of nurse the health-care industry wants to help ease its chronic staffing shortage. He's young--27--in a rapidly aging profession, and male in a female-dominated field that women are leaving in droves. His eagerness to help with any task quickly won over his fellow nurses on Five South, a medical-surgical unit at Kaiser Permanente's Woodland Hills Medical Center.
Unfortunately for Five South, Umali will be gone in a matter of weeks. He will be working at a Maryland hospital and, after that, at a hospital in Honolulu.
Umali is a traveling nurse who works in three-month stints. He gets his assignments through a San Francisco-based medical staffing services company aptly called Across America. "I get a housing allowance. I get a free rental car, free air fare. They pay for everything," he said.
Umali exemplifies the rapid changes overtaking the nursing profession as hospital companies seek creative ways to cope with the high turnover and shortage of qualified nurses.
The big chains are paying signing bonuses for these traveling free agents of the industry, raiding one another's staffs and helping nurses repay their student loans in exchange for a commitment of as little as three months of work.
They say they are attacking the staffing problem by providing funding for training programs and nursing school faculty; scholarships; better working conditions, equipment and pay; and more convenient continuing education.
Hospital operators also are using technology and redesigning hospital wards to change the way nurses work. Kaiser, for example, has designed Five South to make the patients' beds closer to the nurses stations to minimize walking and reduce fatigue.
Tenet Healthcare Corp., the nation's second-largest hospital operator, is giving nurses short-range mobile phones to help improve communications and is conducting pilot studies of computerized order-entry systems and electronic medical records. It also is providing mentors to recent nursing school graduates during the crucial first 90 days on the job, when nurses are deciding whether they can handle the work.
"We're all competing for the same pool of nurses. That's always been true but more so now," said Alan Ewalt, executive vice president for human resources for Santa Barbara-based Tenet.
Some Say Hospitals Created Shortage
But many veteran nurses say the hospitals are going about it wrong. Their anger can be seen in a lawsuit filed this month by the United Nurses Assn. of California against Tenet, charging that the company provides inadequate staffing of registered nurses and violates California labor laws by failing to pay for work breaks.
Many regular staff nurses--most of whom have not seen a bonus or a student loan forgiveness package, much less free air fare or rental cars--say the hospitals and managed-care companies created the shortage and are wasting millions of dollars annually paying inflated salaries to temporary nurses while members of the hard-working rank and file struggle along.
"Millions of taxpayer health dollars are wasted on vacuous retention schemes that really go nowhere," said Rose Ann DeMoro, executive director of the California Nurses Assn., the most vocal and aggressive of the industry's labor groups. "What they are doing now is putting beautiful paint on a rusted-out car."
In Umali's case, all those perks may not be enough to keep him in nursing long term. He says he plans to open his own medical staffing company in a couple of years.
More than 126,000 nurses are needed to fill vacancies nationwide, according to the American Hospital Assn.
That problem will only grow worse over time, said Dr. Peter I. Buerhaus, professor of nursing and senior associate dean for research at Vanderbilt University in Nashville. Buerhaus said the shortfall in registered nurses will reach 450,000 by 2020 as the 78 million baby boomers age.
Taking inflation into account, since 1993 wages for nurses have declined every year except 1998 and 2001, he said, and that has driven more veteran nurses out of the field. The managed-care emphasis on shorter hospital stays means that nurses see more patients each day. Patients who are admitted for longer periods tend to be the sickest ones who need the most attention.
Fewer Younger Nurses in the Work Force
Buerhaus said the current nursing shortage began in 1998 in intensive-care units. Many of the youngest nurses had opted to work there and in emergency rooms, and they experienced early burnout.
"They were fresh. They were bold. They didn't know any better," he said.
The number of registered nurses younger than 30 has dropped 41% since 1983 to less than 10% of the work force, Buerhaus said. The average age for nurses is 43.3, and that will increase to more than 50 in the next eight years, he said.
Fewer people are going into the profession, and those who do seem to be wary of a long career in the field. Nursing school faculties also are aging and diminishing, leaving too few people to teach even if interest in the profession were rejuvenated.
Marie J. Cowan, dean of the UCLA School of Nursing, said the nursing shortage is particularly acute in California.
"We are already working below the margins," Cowan said. "There are too few educational slots to teach an adequate number of nurses, and the rest of the country is already having a hard time attracting people to the profession."
A recent report by Watson Wyatt Worldwide said salaries for "hot skill" jobs in the health-care field are increasing at a dramatic rate. But the pay increases are not reaching everyone.
An American Hospital Assn. survey of U.S. hospitals found that about four in 10 are paying signing bonuses. Three-quarters of those bonuses to registered nurses are in the $1,000-to-$5,000 range, and some go as high as $15,000. In one case, a nurse received $10,000 for a six-month commitment, the survey found. Bonuses also are being paid to persuade nurses to take the least-favored work shifts.
Competition Is Driving Salaries Higher
More than half the hospitals are using temporary agency or traveling nurses, with some filling as much as 6% of their staffs with nurses who travel from post to post. Three-quarters of the hospitals that hire traveling nurses pay them 20% more than they pay regular staff nurses.
The hospitals are competing with other facilities that require skilled nursing care. In one instance cited in the survey, a hospital was forced to raise salaries 15% to compete with facilities that provide long-term care.
That kind of wage pressure is unavoidable, Tenet's Ewalt said. He said his company could hire 1,000 nurses today and still be short of its needs.
"We know every year it will be more expensive, but it's very difficult to come up with a cost estimate," he said. "Our focus is heavily on retention, and we're doing a lot of things to measure employee satisfaction."
Tenet, which runs 116 hospitals in 17 states, including 33 in Southern California, says that this year it is holding its hospital administrators accountable for reducing turnover rates by tying their performances to bonus packages.
But Tenet, like other hospital chains, is facing disgruntled nurses and charges of unfair labor practices at some of its hospitals.
Sherry Stoddard, 48, a nurse at Tenet's Sierra Vista Hospital in San Luis Obispo, said: "Wages are not at all close to local cost of living. It's very expensive to live here, and people are leaving the area because they can no longer afford it. Nurses come here to apply for jobs, look at the wages, look at the cost of housing--and they leave. Tenet could afford to pay more."
Nurses who work for other hospital chains also complain about mandatory overtime.
"Basically, you have to get over the notion that you can go home when your shift ends," said DeMoro of the California Nurses Assn.
Many also grouse about being shifted to wards for which they are not trained. Some of the issues, including reducing the number of patients for which a nurse is responsible, have been addressed in California by the state's new minimum staffing law.
But the hospitals know they must do more.
Sutter Health, Northern California's largest care network, says it has created RN Agenda, a program to improve satisfaction and quality of work life; enhance compensation and benefits; expand opportunities for career growth, continuing education and training; and tout the nursing profession in elementary and secondary schools, according to Ken Buback, Sutter's vice president for human resources.
Hospital Ward Shows Challenges Ahead
One place in which the struggle to retain and recruit full-time nurses is on sharp display is Kaiser Permanente's Five South. Some of its best-trained registered nurses have been promoted to other duties and are rarely involved in direct bedside care.
Among the nurses on Five South is someone who might be every hospital's archetype: a 48-year-old bedside nurse who is not burned out; who has no interest in promotions; who gets cards, phone calls and chocolates from former patients; and who mentors nursing school graduates in their first days on the job.
Katherine Grandchamp is rarely at a loss for words, but she doesn't have many when asked about what it will take to recruit more people to the nursing profession and then get them to stay on the job.
"I have no idea," she said. She added that when she visits elementary school students on career day, "they always ask me why I didn't become a doctor instead."
Five South looks more like a traditional intensive-care unit than most hospital wards because it's designed with a central nurses station and without long hallways. Patient rooms surround the station, enabling nurses to monitor their patients without long walks.
An electronic voicemail system eliminates the need for paperwork reports or face-to-face contact between nurses at shift changes. The nurses use voicemail to listen to overnight nurses describe each patient's night on the ward. Electronic prescription drug machines eliminate trips to the pharmacy and the familiar sight of a nurse walking with the ward's medications in small cups on a tray.
Kaiser has its work cut out for it, even in units such as Five South, which were designed to make life as easy as possible for nurses.
Yelina Kochergin, a 29-year-old native of Russia, gets tuition reimbursement and full benefits from Kaiser Permanente even though she works part time, putting in 40 hours every two weeks as a bedside nurse. Kochergin, said Grandchamp, who served as her mentor, is the kind of nurse the hospital needs full time.
But that's just not in the cards, Kochergin said. "I need time to recuperate. I don't think I would want to [work] full time because of the stress level, dealing with patients' families."
Other registered nurses assigned to the unit are no longer involved in direct patient care.
Verna Palanas, for example, has become the charge nurse; among her other duties, she assesses the workloads of the nurses on her shift and decides who has the least needy patients and can take on the newly admitted.
Another registered nurse, Stacy Silver, has become a case manager. Silver spent much of a recent day trying to ensure that a newly discharged patient would get home care.
Grandchamp tirelessly worked through an "easy" day on the unit. There were no medical emergencies, very few new "admits" and most of the patients were progressing nicely. She displayed the energy that helped her raise five children before deciding to become a bedside nurse at 41.
"I love bedside nursing. I try to lead by example," she said. "The other nurses know I love my job."
For many of those who have left the stresses of bedside nursing, the jury is out on whether they might go back.
Deborah Burger, 51, a Kaiser Permanente nurse in Santa Rosa, Calif., now works as a diabetes case manager, a job "that allows you to have reasonable hours."
Burger said she would consider a return to bedside nursing "once the California staffing ratios are implemented."
"But I don't know," she said. "I like having weekends off."