Old Timer's Take on Fixing the Nursing Shortage

The nursing shortage has been exacerbated and accelerated by the Pandemic, no doubt about that. We need to replace those who have left and educate them even more to fill that gap. I am a firm believer in the "old way" of training, with additional post-training academics.

Updated:  

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. 

Reasons for Nurses Leaving 

  1. Exhaustion
  2. Timely or early retirement        
  3. Refusing to get a mandatory COVID vaccine
  4. Going to travel nursing for better pay
  5. Family concerns during COVID
  6. Safer easier assignments elsewhere
  7. Sickness or death
  8. Pursuit of higher education
  9. Violence on the job, or 
  10. 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.

kathy-graduation.jpg.c7ed0572c38b5436f057cec9784af746.jpg.704bce56fc6a7c766a153f732b58db0e.jpg

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.

Specializes in CRNA, Finally retired.
On 5/22/2022 at 10:41 AM, Tweety said:

The initial idea was that it cut down on incidental overtime.  People that were scheduled to work 40 hours routinely worked over 40 hours just to get things done.  The other thing it was the preference of the majority of the staff.  The problem with offering 8 hours and 12 hours if you have to have someone to match the 8 hour people three times a day and someone to match the 12 hour person.  Otherwise at 3, 7 and 11 you're shuffling assignments around because not enough people want to work 8 hour shifts.  Easier I suppose for administration to have everyone on the same page.  But I can see that in this time of shortage, maybe offering 8 hours would be an incentive.  

 

No, it doesn't work with people on the same floor working differently houred shifts.  Units would have to designated 8 or +12's on inpatient units.

Specializes in Med-Surg.
4 minutes ago, subee said:

No, it doesn't work with people on the same floor working differently houred shifts.  Units would have to designated 8 or +12's on inpatient units.

Yes.  Back in the day you could work 12 hour shifts if you found a match on the opposite shift to work the same schedule.  

Now if we offered 8 hours you'd have to cover 3 shifts with 8-hour workers and the demand to work 8 hours just isn't there anymore and I would venture a guess staffing a unit with nothing but 8 hour workers would be difficult, but it could be done I suppose and would satisfy a niche for nurses that need to do this for their families, or people whom 12 hours is just too physically grueling.  

Specializes in Geriatrics, Dialysis.
18 hours ago, subee said:

No, it doesn't work with people on the same floor working differently houred shifts.  Units would have to designated 8 or +12's on inpatient units.

It sort of worked having mixed 8's and 12's at the SNF I worked for. A previous DON came up with the idea to try the 12's for those  that were interested. I'm sure it would have been to their advantage if all the nurses were on board as they could have reduced nursing  staff by 1/3 since it took 2 nurses instead of 3 of cover 24 hours but as it turned out there were not very many interested. Only 6 of us signed up for it and those that did work the 12's had to be super reliable employees, if one half of the 12 hour team called in it was almost impossible to fill the full 12 so my 12's pretty often turned into 16's.

Specializes in nursing leadership/medsurg/tele/ICU.

You have great perspectives on how we can retain and better prepare future nurses. Nursing is hard work. Even harder with higher patient expectation, more patient focused, incentives for organizations when meeting patient expectations and quality care.  Sometimes I think health care is becoming more health cost. 

Specializes in Critical Care.

I agree with the majority of what you post. the only bits where I might disagree come with the idea that unless youre “in it” (doing nursing school and figuring out nursing without years of experience here and now) you cannot fully understand what its like to be “in it.” - and tho that is real, you covered so much and much of what you posted makes sense. so focusing on that:  

what would it take to go back to some of the old ways? especially the hands on training?

the restrictions are ridiculous! during my peds rotation, I was not allowed to give many medications and even PO tylenol required supervision at all times. no exceptions. one was very lucky to get exposure to critical care, ED, NICU, L&D etc (basically any specialty areas). far and few got those opportunities even during the last semester of school. if one hoped to see the OR, or any sort of intra procedural area… forget about it. aint gonna happen. I got really frustrated one day, and sternly but respectfully asked a professor once about the restrictions. Summary was: “too much risk.” 

 last year, I was working in IR and was assigned to work intra op, and one of my patients was a retired nurse that graduated from nursing school in the late 1950s. She was an amazing (and hilarious) human with SO many great stories. Learned a lot and got a glimpse of how things once were and how things could be better in the nursing world. she had to work hard in nursing school and really hard being in the workforce, college education, during a time when it was not so popular for women to do so. 

side note: I have my RN, BSN + following certs: BLS, ACLS, PALS, CCRN… and strongly feel that none of the alphabet soup of letters trumps solid training and hands on experience.

other personal thoughts: the more I hear and learn about how things were done before, the more I feel that any nursing programs out there these days are a joke. I learned more in my first year working as a nurse than the entire 4-5 BSN program I spent 50k on “earning” 

Specializes in oncology.
9 minutes ago, BeatsPerMinute said:

if one hoped to see the OR, or any sort of intra procedural area… forget about it. aint gonna happen. I got really frustrated one day, and sternly but respectfully asked a professor once about the restrictions. Summary was: “too much risk.” 

The last hospital I taught at had specific guidelines about what students could do on their own....nothing! Not even an accuchek!  The faculty member had to supervise all medication administration, any urinary catheterization, NG insertion, would dressing care etc. I had 10 students with 10 acutely ill patients with multiple IV medications. There is only so much time..

With regards to the OR:  There were 3 pages of guidelines. I had to walk the 2 students allowed that day at a designated time ( one hour before the clinical start time) to outside the OR and wait for the appointed person to appear and steer the 2 students to their cases. The guidelines were specific about NO jewelry but I missed one student out of 20. The OR appointed person  made sure to pull me out of a patient room later to show me my transgression (with cheap costume jewelry in her hand). But there you go....gatekeepers to learning. This has changed in my nursing education role from 1979 to now....

Specializes in CRNA, Finally retired.
1 hour ago, londonflo said:

The last hospital I taught at had specific guidelines about what students could do on their own....nothing! Not even an accuchek!  The faculty member had to supervise all medication administration, any urinary catheterization, NG insertion, would dressing care etc. I had 10 students with 10 acutely ill patients with multiple IV medications. There is only so much time..

With regards to the OR:  There were 3 pages of guidelines. I had to walk the 2 students allowed that day at a designated time ( one hour before the clinical start time) to outside the OR and wait for the appointed person to appear and steer the 2 students to their cases. The guidelines were specific about NO jewelry but I missed one student out of 20. The OR appointed person  made sure to pull me out of a patient room later to show me my transgression (with cheap costume jewelry in her hand). But there you go....gatekeepers to learning. This has changed in my nursing education role from 1979 to now....

If hospitals don't re-dedicate themselves to institutions of learning for nurses (do they restrict medical students in this manner?), then they are NEVER going to have enough staff because they are already missing the big picture of what's going wrong.

I really enjoyed my job when there were Jr and Sr nursing students, LPNs, LPN students, CNAs, Jr CNAs, RT + students, PT + students, OT + students, Med students, interns, residents, fellows who all worked together and were not afraid to ask for help lifting, moving a patient ... etc., etc..... 

Specializes in Med nurse in med-surg., float, HH, and PDN.
2 hours ago, CathyGubersky said:

I really enjoyed my job when there were Jr and Sr nursing students, LPNs, LPN students, CNAs, Jr CNAs, RT + students, PT + students, OT + students, Med students, interns, residents, fellows who all worked together and were not afraid to ask for help lifting, moving a patient ... etc., etc..... 

That's the way to do things! We had sufficient staffing, and there was always someone to help out if needed. They divvied up the patient assignments so that no one ended up with the all the hard/difficult patients and no one refused to help out for a few minutes with certain procedures. I was the med nurse on 3-11, and the charge nurse and I would take up to 4 patients between us. There were 3 CNA's who split up the rest of the patients, some who they doubled up on, and some they each worked alone.  

As a diploma student we did 8 week rotations, into the OR and on day one were taught to scrub, sterile technique, worked in sterile supply (back in the day we double-cloth wrapped items for sterilization), learned what was in simple packs. Then we went into pre-op and then post-op. Finally got to scrub and became 2nd and then 1st assist during surgery.  In my senior year I was allowed to work weekends as part of the skeleton crew that staffed for emergencies. We were not a trauma center. This was an excellent experience on my part! Never had a problem gowning, gloving correctly and maintaining sterile protocol.

Specializes in Patient Safety Advocate; HAI Prevention.

I had several weeks of OR training as well, Pre and post op, and scrubbing in.  And like you we learned to clean and repack instrument packs.  My first job as an RN was in the OR/ER/sterile supplies department of my small hometown hospital.  I had all of the basics on board to do that job and the many aspects of it.  This was in the days of sterilizing and centrifuging glass/mercury thermometers!  So much has changed, that is for certain.  But, the need for scrupulous sterile technique will never change, and those basics were given to me and my classmates in an excellent 3 year nursing diploma program. 

Specializes in Kidney Transplant, Case Management, Oncology.

These are great ideas, Kathy! I agree that going back to the "old training" or fundamentals of nursing is important. I feel that there was a great emphasis on nursing theory, micro pharmacology (the level of detail that is more useful to a Pharmacist that a Nurse) and other areas of study in nursing school, that are not as useful in the day to day of being a nurse. Although these other topics are important, they do not need to be at the forefront of nursing education. It would be better to prioritize nursing and clinical skills. These are the tools needed for safe practice and to increase the best outcome for your patient. Developing these skills will develop confident nurses.

Today in healthcare, there is a significant emphasis on charting for the sake of meeting Medicare standards and to avoid liability. Unfortunately, this often takes away from patient care. Some of my colleagues who started working as a nurse in the 1970's and 80's have shared with me that they felt that they had the ability to practice actual nursing care during that time compared to today.

I agree that Nurse Educators are also necessary. I worked with two wonderful Nurse Educators in my first four years of nursing. They provided education to oncology patients who were receiving chemo for the first time. However, they also provided education to the nursing staff. 

Definitely appreciate your insights!