Old Timer's Take on Fixing the Nursing Shortage

*KathyDay*

The nursing shortage is starting to hurt, really bad. These past few years have worn down some of the strongest and most talented nurses in the US, and they have either quit nursing or moved to greener Nursing pastures. Sadly, this happened smack in the middle of a horrible pandemic when they were needed the most. Their reasons for leaving were many.

Exhaustion
Timely or early retirement
Refusing to get a mandatory COVID vaccine
Going to travel nursing for better pay
Family concerns during COVID
Safer easier assignments elsewhere
Sickness or death
Pursuit of higher education
Violence on the job, or
They were just plain sick of it. Burned out, PTSD, emotionally drained

Too many of them were all wrung out. They didn’t have anything left to give. Nurses are human too.

An article in the Bangor Daily News before the pandemic discussed nurse retainment. One hospital spokesperson stated that over half of new graduates left their new jobs before their first year was up. They started replacing nurses with foreign nurses. I wonder what they discussed in their exit interviews. Did they ask WHY they left? If they asked, what were the answers? That was not covered in the newspaper story. It made me wonder what they were doing to address the reasons that new nurses left.

Could it be that they were not staffed well enough? Were they given a long enough training period with a preceptor? Was the pay good? Were they treated with respect and taught the ropes with patience?

I don’t pretend to have all the answers, but I am an old nurse, and I have learned a thing or two. Every patient is different, and so is every nurse.

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When I trained in nursing in 1967 (graduated in 1970), we started practicing our book learning in the second half of our first year. I trained in a School of Nursing. It was a 3-year program in a Catholic Hospital school, with rules, lots of rules, and very few vacation breaks. We went to school and trained year-round. Our fees covered books, room, board, schooling, and uniform laundering. If my memory serves me well the cost of our program for 3 years, all year, was around $1500... I had a federal loan that was partially forgiven by my work after graduating. A nursing student couldn’t pay for books for that amount these days. I paid the balance of my loan, around $800 several years after I graduated. I was never strapped with student debt and exorbitant monthly payments.

Our first semester gave us all the necessary sciences. The second semester we dove right into actual nursing fundamentals, and beyond that, we learned pharmacology and practiced in all of the specialties. With the supervision of our instructor, we did all of the work of an RN. We passed meds, and took full patient assignments. We work/studied OBS/GYN, Med/Surg, psychiatric nursing, Operating room and recovery, pediatrics, and ICU. We spent a good slug of time (generally a month or more) in each specialty and did our studies and hands-on practice simultaneously at times. We also worked shift work with regular staff and in our senior year, we did Charge Nurse duty (all with instructor supervision).

During our training, no cheating was allowed and we were monitored for it. If you failed a subject, no matter how hard you worked, you were dismissed and had to repeat that entire year. I always thought that was harsh, and that perhaps some tutoring might have been fairer.

My program was very tough. I was never so proud or relieved as the day I graduated from that school. When I left, I felt like I had the world by the tail and I was a fully prepared nurse. I passed my boards with flying colors on the first attempt. And, that was while I was sick with a horrid sore throat and fever!

I sincerely believe that an attempt to “get back to basics” is the way to go. I admire and know many college-educated newer nurses. I also know that they did not start their first jobs with the same confidence that my classmates and I did. We were very confident in our skills because of hands-on training.

A 4-year program is fine, if you want to be a well academically rounded new nurse who will need a lot of nurse training once you start your first job as an RN. Since there are barely enough nurses to go around, is that realistic…to have that expectation of your new employer? Can an already overloaded staff nurse mentor you and still take safe good care of her own patients?

My idea is this:

Go back to the old training, and know that once a student graduates, they are prepared to do the job of a bedside RN from the get-go. Offer these programs free, to anyone who qualifies and find a way to do a lot of the coursework remotely, so a student can do much of their training while at home. Set up satellite classrooms remote from the nursing school. Organize housing for students when they need to be away from home for in-hospital nursing training. Also, attract them with the promise of an excellent position and salary and potential for advancement when they graduate. Employers can then offer tuition reimbursement for nurses who want to work for them while they pursue higher education, like a BSN, MS or PhD. While they continue their nursing education, they can be an already “trained” RN, earning a living in a hospital or LTC. We also need nurse educators, so additional education is necessary for that as well. I know that some of “my” ideas are not original and that some facilities and schools offer a lot of what I suggest. But this has to be widespread and the commonly accepted approach to nursing recruitment, education and retainment. If schools and facilities and other nurses do not make nursing attractive, we will not get new nurses.

The work of an RN should be based on caring, curing, rehabilitating (when possible), educating and prevention. Another very important part of nursing is guiding patients and their families through their last days. None of these things can be done in a hurry, yet every time a nurse goes to work at the bedside, whatever facility they work in, they face a rapid-fire marathon of work. There is little or no time for actual caring….a little hand-holding, a compassionate conversation with a patient or family member, an extra touch, maybe even a little skincare. And, the nurses’ basic needs like using the bathroom or having lunch are often not met. That is just not right. The job is just that…a job. We want it to be a calling again.

Nothing has highlighted the short fallings more than the care of Covid patients during an overwhelming pandemic. We can’t allow this to continue. Nursing is not the same as a production line, yet nurses are expected to work that way. It is evident by the long-standing understaffing of facilities where physical and mental speed is a constant expectation…and slowing down for caring and compassion is not. Profits are the ruling factor in healthcare facilities and that is just counterintuitive to the calling.

We will never attract young people to nursing if we allow the current pace and disrespect of nursing to stand. There are just too many other attractive professional opportunities that compete with nursing. But we can change. We can change how or if we have to pay for nursing education. We can change nursing education itself….by starting with “training” and continuing with broader advanced education. Perhaps even earlier nurses training prep can start in high school We can change the work of nurses. Most importantly, we can change the quality of the work and patient care and safety if all of these steps are taken.

I don’t have a miraculous way to pay for all of this, but we need to find a way. If not, then people like me, a 73-year-old woman, will be hard put to find nursing care for ourselves when we need it.

GrumpyOldBastard, MSN, RN · May 20

I agree with most of what you say! In my years as an instructor in an Associate Degree nursing program, I saw many smart students who chose a path very similar to what you propose. These were students who could have attended a generic BSN program, but chose to attend our ADN program to get lots of clinical time and emphasis, and follow that with an online RN to BSN program. In many cases they were able to get their employer to pay for the ADN, and in most cases they got the boss to pay for the BSN. These students felt that this allowed them to get “the best of both worlds”… given the options that they had.

It is true that decades ago the diploma program students often were doing essentially all of the RN job and RN workload before graduation (under supervision). I would argue that the increased acuity and complexity of care for the majority of inpatients today makes this a less reasonable goal. Certainly some modern students are able to take on a large portion of a nurse’s role and load… but the vast majority of students are not.

Davey Do · May 20

No reaction was available to truly convey my feelings toward your article, KathyDay, so please allow me to give you this:

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Your nursing story is a truly exquisite read! Thank you for such a descriptive, heart-warming experience! Wow!

And your perspectives and fixes are incredible! Again, I say, "Wow!"

I could go on and on, but suffice it to say, "Great article!"

P.S. I worked and recently visited with a nurse who graduated in 1967. She is 76 years old, still sharp as a tack, and continues to work!

rentalnurse, RN · May 20

New grads are very “smart” and can give you lots of evidence based practice information but practical stuff ie changing beds, bedpans , patient care etc well… some consider that the “techs” job. This has always been this way for some but lately especially since COVID has limited their practicum time seems worse.

GrumpyOldBastard, MSN, RN · May 20

Unfortunately, this is sometimes reinforced by mis-guided faculty: “With a BSN you will be the manager.”

*KathyDay* · May 20

On 5/20/2022 at 9:32 AM, GrumpyOldBastard said:

I agree with most of what you say! In my years as an instructor in an Associate Degree nursing program, I saw many smart students who chose a path very similar to what you propose. These were students who could have attended a generic BSN program, but chose to attend our ADN program to get lots of clinical time and emphasis, and follow that with an online RN to BSN program. In many cases they were able to get their employer to pay for the ADN, and in most cases they got the boss to pay for the BSN. These students felt that this allowed them to get “the best of both worlds”… given the options that they had.

It is true that decades ago the diploma program students often were doing essentially all of the RN job and RN workload before graduation (under supervision). I would argue that the increased acuity and complexity of care for the majority of inpatients today makes this a less reasonable goal. Certainly some modern students are able to take on a large portion of a nurse’s role and load… but the vast majority of students are not.

Of course nursing has changed (scientifically and technically), and nursing education must change as well. The supervised hands on approach is the best way to build confidence to safely care for patients. Specialty training should start during "training" and continue after becoming an employed RN. The education of a nurse doesn't stop after the program...it is ongoing. I can't remember a time during my own career that I stopped learning. Maybe that is something that needs to be emphasized during early days of a nurses learning. In my article I mentioned some sort of prep courses during high school. A very basic layer of nurses training could start there... I know that some high schools offer free CNA training, and that could be the beginning for ongoing nursing education. I remember nurses who thought they were finished with learning once they graduated whatever program they took. Those were the nurses who were the hardest to mentor and who needed the most supervision it seems.

Thank you for your comment and for your work!

*KathyDay* · May 20

1 hour ago, rentalnurse said:

New grads are very “smart” and can give you lots of evidence based practice information but practical stuff ie changing beds, bedpans , patient care etc well… some consider that the “techs” job. This has always been this way for some but lately especially since COVID has limited their practicum time seems worse.

I hadn't considered this. I did observe that a lot of programs accelerated their programs to allow students to fill the gap at hospitals at the peak of the pandemic. I wondered about the impact of this on patients and other nurses. It seemed both wrong and necessary. Sometimes there just is no answer to the problem.

Okami_CCRN, BSN, RN · May 20

I think one of the larger issues affecting the nursing profession is that hospitalized patients are getting sicker, yet staffing does not represent that change.

Patients who are currently on med/surg units may have been in step-down/ICU 20 years ago, yet floor nurses are expected to provide efficient, evidence-based, and safe care for 7-8 patients on any given shift.

When I get the chance to talk to nurses who transitioned to ICU, they always mention the same theme; feeling like they were just putting out small fires and an inability to promote wellness and prevent decline.

I truly believe that one of the largest benefit to nursing retention is the implementation of safe and appropriate ratios.

*KathyDay* · May 20

On 5/20/2022 at 12:24 PM, Okami_CCRN said:

I think one of the larger issues affecting the nursing profession is that hospitalized patients are getting sicker, yet staffing does not represent that change.

Patients who are currently on med/surg units may have been in step-down/ICU 20 years ago, yet floor nurses are expected to provide efficient, evidence-based, and safe care for 7-8 patients on any given shift.

When I get the chance to talk to nurses who transitioned to ICU, they always mention the same theme; feeling like they were just putting out small fires and an inability to promote wellness and prevent decline.

I truly believe that one of the largest benefit to nursing retention is the implementation of safe and appropriate ratios.

You are absolutely right...ratios are a must. And those ratios have to reflect the rising acuity of patients. Specialty training should be ongoing inside the facilities that hire nurses...along with required certifications. Nursing "training" never ends, no doubt about that. It is ongoing and schools at all levels AND facilities must provide related appropriate training and staffing.

*RN WRITER NC, ADN* · May 20

Awesome article, good points and valid answers! Congratulations for your well-thought ideas!

CathyGubersky · May 20

I agree with Kathy Day totally! When I went to the first 2 year RN Diploma program at South Chicago Community Hospital 1972-1974 (Had been a 3 year program up to that point) I had already been working 20 hours per week during high school as a Junior Nurse's Aide. Our first year of school was mornings in class, afternoons on the floor. We put into practice what we learned right away. Yes, by senior year we would go into locker room and change out of our grey pinafores of a student into white of a nurse, and take over for 3-11 shifts, 11-7 on Fridays or Saturdays: as long as we held a B average in class. No instructor on floor, just nursing supervisor or charge nurse. There was a terrible nursing shortage. 72 nurses signed up, 41 graduated 2 years later. Majority passed those awful 3 day boards in June 1974. Majority of the graduates STAYED TO ADEQUATELY STAFF THE HOSPITAL. Yep, it was that bad. But we walked out onto the floor DAY 1 knowing what to do and how to do it. And the State of Illinois paid my tuition and books and fees!

I retired last year and firmly believe how I was trained is how we need to do it. Team Nursing instead of Primary Care nursing would speed up the patient care, and decrease the workload on the RN. EIGHT HOUR SHIFTS - there were many days I worked eight hour shifts in ICU, ER, Telemetry, O.R., MedSurg where I was exhausted. Later in life when 12 hour shifts were mandatory there were times I went home and wrapped my legs in a heating pad because of leg cramps. In this day and age of increased acuity just to be admitted, eight hours is long enough to be on high alert. More down time is needed.

Working 8 hours, five days per week, meant you worked with the same people and got to know their strengths and weaknesses so you could work together. True friendships and comradery could develop, and there was time for non-work time activities together such as soft ball games, bowling leagues, etc. With 12 hour shifts you are lucky if you work with the same nurse more than 3x per month. And everyone just wants to finish charting and get home to the 3 hours of "down time" family life before sleep. Actual friendships are rare to develop and I believe this feeling of loneliness leads to burnout. And I would think this is also present among travelers.

Just my thoughts on the current nursing shortage.

Cathy Gubersky RN, MS

subee, MSN, CRNA · May 20

A brief history of nursing education americansentinel.edu

1909: The University of Minnesota School for Nurses becomes the first university-based nurse training program. It awards a baccalaureate degree to students that complete a three-year program.

1923: A study known as the Goldman Report concludes that nurses should ideally be educated in a university setting, according to academic standards.

1948: The Carnegie Foundations studies nursing education and publishes the Brown Report, again recommending that nursing schools be placed in academic settings rather than hospitals. Regardless, hospital-based diploma programs continue to be the norm, training the vast majority of American nurses and focusing on filling open nursing positions.

1952: A project at Columbia University introduces the concept of two-year, associate degree nursing programs as a research-based plan to test this new education model. The curriculum is composed of half nursing classes and half general-education classes, with clinical experiences gained in the community.

1960-1975: Diploma programs decline rapidly as they are replaced by associate’s degree programs at community colleges.

1982: Even as the ADN remains the most common degree held by working RNs, the National League in Nursing (NLN) releases the first position statement to affirm the BSN is most desirable as the minimum educational level for entry-level nurses. Over the next three decades, many other organizations adopt the same position.

I also read that federal funding for nursing students didn't begin until the 1960's at the same time that the BSN was being encouraged so students were incentivized to use that money in a community college or a 4 year program. If I were queen, I would have students go anywhere for 2 years of pre-nursing classes anywhere and then step into a program for the last two years that ran year around, 24/7 like the diploma programs. Students would be permitted to provide some labor to the hospitals to keep costs down for the students and hospitals would have graduates ready to work immediately upon graduation.

Old Timer's Take on Fixing the Nursing Shortage

Promise nurses the moon, and then give it to them.

My idea is this:

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