Critical Condition

The following story is reprinted with permission from Nurse Week magazine. Visit their Web site at www.nurseweek.com

Nurses and health care institutions already are struggling with it and searching for solutions. Experts say improving the workplace and polishing the image of nursing are among the steps that must be taken to avert a potential catastrophe in health care.

In a military town, Suzanne Purdy, MBA, RN, partially handles rapid staff turnover by hiring married registry nurses. The benefits of a full-time job aren't as much of a lure for them, she said, if their military spouses supply the medical/dental coverage.

But the expense and stress of constantly training new part-time registry nurses takes its toll on her.

Out of necessity, Purdy, vice president for patient care at Paradise Valley Hospital in San Diego, a Christian-owned, nonprofit community hospital with 302 beds, also hires new grads for positions in the definitive observation unit.

In the past, Purdy would have held out for more experienced nurses. Some of the new hires do come from skilled nursing environments but haven't worked in acute care for a while, she said. They usually require special refresher education and clinical precepting to return to the bedside. "Then what may happen is they'll leave," she said.

Studies indicate that loyalty is diminishing among Gen-Y and Gen-X nurses, she added. Job-hopping, largely frowned upon by baby boomer nurses, is the norm among their younger cohorts, who often stay exactly as long as their $3,000 to $5,000 signing bonuses say they must, Purdy said. "From my experience, the nursing shortage is acute-extremely acute," she said.

The alarm sounds
Purdy is far from alone. News reports from across the country paint an alarming picture of an acute worldwide nursing shortage that promises to become much worse in the years ahead.

Knowledge of the problem saturates most nurses, but solutions still may look murky. Ominous results of the latest National Sample Survey of Registered Nurses show the supply of nurses-thoroughly reported as insufficient-will slow even further. Sigma Theta Tau International Honor Society of Nursing calls the shortage a major threat to the future of the world's health care system. It's not just a U.S. crisis. Australia, Canada, and parts of Europe and Asia also report problems.

Ominous effects
The most convincing evidence of the nursing shortage is the rapidly rising vacancy rates in every region of the country.

Some hospitals are canceling nonurgent surgeries, closing beds or units and diverting emergency room patients. As a result, some hospitals and nursing homes are unable to admit patients and some home care agencies are unable to take on new clients.

The Texas Hospital Association, for instance, reports rising RN vacancy rates across the state that range from 10 percent to as high as 18 percent in some specialty areas.

In the Dallas/Fort Worth area, the RN vacancy rate is 10.4 percent, while the vacancy rate among RNs working in intensive care units is an alarming 16.9 percent (up from 12.7 percent in 1999). Generally, according to the association, vacancy rates of 9 percent or above are thought to indicate a significant shortage.

In November, nursing shortages forced Johns Hopkins Hospital in Baltimore to leave 10 percent of its surgical beds unfilled, delaying or canceling some surgeries.

In February, Saint Elizabeth Regional Medical Center in Lincoln, Neb., reported an 11 percent vacancy rate in its 435 registered nursing and licensed practical nursing positions.

Why now?
Although nursing shortages have occurred before, today's is different because it is being driven not just by a diminishing supply of new talent entering the profession, but by a growing demand for health care as the baby boom generation approaches its golden years.

The latest numbers from the American Association of Colleges of Nursing indicate that enrollments in five-year baccalaureate nursing schools dropped 16.6 percent during the past five years, from 72,452 in 1996 to 60,443 in 2000. Within 10 years, 40 percent of working RNs will be 50 or older, according to Sigma Theta Tau.

As those RNs eventually retire, the supply of working RNs is projected to be 20 percent below requirements by 2020.

Today's shortage also occurs at a time when nursing has lost some of its luster as a career opportunity, partly because nursing is a traditionally female profession and today's women have more options than they did before. Women graduating from high school in the latter part of the 1980s and during the 1990s were 35 percent less likely to become RNs compared to women in the 1970s, according to the Texas Hospital Association.

What's more, experts say changes in the delivery of health care in a managed care environment have caused some nurses to become frustrated. Their complaints have discouraged newcomers from joining the profession. In a survey released last month by the American Nurses Association, 54 percent said they would not recommend their profession to their children or their friends.

The ANA survey found that 75 percent felt the quality of nursing care where they worked had declined during the past two years. A majority, or 56 percent of the 7,299 nurses surveyed, said they had less time to care for patients. Moreover, 40 percent said they would worry about sending a family member or someone close to them to be cared for at the facility where they work.

The shortage is far from universal at this stage, however. It tends to be felt hardest in isolated rural areas, depressed urban environments and key specialty areas. The numbers indicate that the shortage also is more likely to be felt in Western and Southern states than it is in the East and Midwest.

Solutions on tap
Nursing schools, the obvious route to replenish the pipeline, have a hard time funding adequate numbers of enrollees. Judy Papenhausen, Ph.D., MSN, chairwoman of the department of nursing at California State University, Los Angeles, said new enrollees in the department have increased from 50 to 70 per year. She'd like to double those numbers, but funds are scarce.

The requisite low student-to-teacher ratios in nursing schools mean costs are much higher than in some other departments, such as English literature. "With more money from the Chancellor's office or from the federal government, the schools could admit another whole class," Papenhausen said.

Losing good nurses to other states means that recruitment and retention strategies at St. Alexius Medical Center in Bismarck, N.D., must focus on graduates of the two nursing schools in town.

Linda Knodel, MHA, RN, assistant administrator/director of nursing at St. Alexius, said the hospital tries to keep the local graduates, known for their good work ethic, from accepting offers elsewhere by offering scholarships, serving as guest faculty at the local nursing schools, running job shadowing programs for junior and senior nursing students, providing scholarships for junior and senior students, and offering competitive wages.

Purdy said her adjusted hiring methods might include using a different skill mix to avoid burning out existing staff nurses.

"My hospital is all RNs, but I'm evaluating using LVNs or CNAs as nurse extenders. Then I always encourage them to move up their credentials a notch," she said.

Given the shortage, she said it's not realistic to think she can hire all BSNs with clinical experience and the intent to stay.

Underlying causes
According to the newly released preliminary findings of the National Sample Survey of Registered Nurses, California trails only Nevada in the number of registered nurses per 100,000 population. The national average is 782 employed RNs per 100,000 population.

When the survey was conducted last March, California had 544 employed RNs per 100,000 and Nevada had 520.

On the top end of the scale, the District of Columbia had 1,675 employed RNs per 100,000 population, while Massachusetts had 1,194 and South Dakota had 1,128.

So while no state may be immune from the shortage, especially in key specialty areas, the numbers have led researchers to conclude that some states have more work to do-and more to fear-than others. In California, for example, researchers estimate that the state will face a shortage of 25,000 RNs within the next five years.

Survey results
Preliminary results of the National Sample Survey give nurses a clear idea of approaching patterns in the crisis.

"We have seen a decline in enrollments and graduations. Nurses are getting older and leaving the workplace, and we're seeing a salary issue. If you look at the salary table, there hasn't been much growth on a real scale since 1992," said Denise Geolot, Ph.D., RN, FAAN, director of the Division of Nursing in the Bureau of Health Professions, part of the Health Resources and Services Administration in Washington, D.C., which released the preliminary survey results in February. The HRSA falls under the umbrella of the Department of Health and Human Services.

"The apex of the age curve has moved, so we have 68.3 percent of nurses over 40, which is a real concern. We have a small percentage under age 30," Geolot said.

The supply of nurses has increased during the past four years, Geolot said, but at a slower rate than in the past. It's the lowest increase since 1977. That reflects the lower number of grads entering the workforce vs. a larger body of exiting nurses.

But, Geolot said, "We're pleased that more men are entering. Male nurses made up 5.4 percent of the workforce in 2000, whereas in 1996, they made up 4.9 percent of it."

The number of racial and ethnic minorities in nursing also has increased, she said. In 1996, they made up 10.3 percent of the workforce vs. 12.3 percent in 2000. Still, Geolot said, those numbers are lower than she'd like to see.

HRSA will funnel the data from the National Sample Survey into a forecasting model to be released this summer, which will further help predict nursing supply and requirements in 2010, Geolot said.

The Web site for the survey is www.bhpr.hrsa.gov. Since 1977, HRSA has-every four years-released extensive and comprehensive sources of statistics on characteristics of all nurses with current licenses to practice, Geolot said. The 2000 survey went out to 54,000 nurses. Of those, 4,520 were excluded because of duplicate licensure, so the survey polled a total of 49,480 nurses, or 72 percent.

Of course, Geolot said, there's lots of interest in looking into solutions about the future; many states are investigating strategies and congressional hearings lately address legislation toward reducing the shortage.

Improving the image
The good news is that much already is being done in an effort to reverse the trend.

In Massachusetts, unions and employers are pushing for the Clara Barton Act proposed by state Sen. Richard Moore, D-Uxbridge, who heads the Legislature's joint committee on health care. Named for the Massachusetts nurse who helped to professionalize nursing, the bill would provide $25,000 starting bonuses over several years to new nurses in the top 15 percent of their classes, similar to bonuses given to teachers.

In Nebraska, Saint Elizabeth Regional Medical Center instituted a three-part program for new nurses in August. It includes a preceptor program to help new hires with their clinical and technical skills, a mentoring program to help them adjust to hospital culture and personalities and a commitment program with financial incentives ranging from $500 to $1,500 to stay for three years.

In Texas, state Sen. Mike Moncrief, D-Forth Worth, and Rep. Patricia Gray, D-Galveston, have introduced the Nurse Shortage Reduction Act of 2001. The legislation, among other things, would double nursing school capacity during the next five years in a state where thousands of qualified applicants are being turned away.

Two years ago, according to the Texas Hospital Association, a lack of budgeted faculty positions was the primary factor in forcing nursing schools to deny admission to 2,225 qualified applicants to associate degree or diploma programs, and to 788 qualified applicants to baccalaureate and master's programs.

Dorel Harms, RN, vice president of professional services at the California Healthcare Association, emphasized late last year the importance of recruitment at nursing schools. The California Nursing Outcomes Coalition is addressing the images of nursing and how nurses are recruited, Harms said.

Patricia McFarland, MN, RN, executive director of the Association of California Nurse Leaders, said late last year, "We have to do an imaging campaign. We need to work with young people to dispel a lot of myths about nursing. We need to attempt to bring [prospective students] in before the freshman year in high school.