Special Feature
Jun 03

The Nursing Shortage
Separating Fact From Fiction
A Kelly Healthcare Resources Report

In one of Aesop's lesser-known fables, a goatherd was driving his flock from their pasture one evening when he discovered some wild goats mingled among his flock. He locked them up together with his own for the night.

The next day, it had snowed so heavily that he could not take the herd to their usual feeding places and he felt obliged to keep them in the fold. He gave his own goats just sufficient food to keep them alive, but fed the strangers more abundantly in the hope of enticing them to stay with him and making them his own.

When the thaw set in, he led them all out to feed, and the wild goats scampered away as fast as they could to the mountains. The goatherd scolded them for their ingratitude in leaving, reminding them that during the storm he had taken better care of them than his own herd.

One of them, turning about, said to him: "That is the very reason why we are so cautious; for if you yesterday treated us better than the goats you have had for so long, it is obvious that if others came after us, you would in the same manner prefer them to ourselves."

PARALLELS WITH NURSING

The goatherd in the story faced no shortage of goats. Rather, it was his lack of vision and leadership that created an inhospitable environment—one that forced the goats to look for greener pastures. As prospects, the goats were highly prized, courted and valued. Once part of the flock, however, they realized they would be taken for granted.

Like the goatherd, today's healthcare industry has been longer on the promise than on the delivery. Unwittingly, it has created an unhealthy environment for nursesóone that is forcing many to exit the profession and others that may have pursued a nursing career, to look for other professional opportunities.

The numbers provide the grim reality. In study after study, the supply of nurses is dropping precipitously as the demandódriven by an aging population with more acute care needs—increases.

"There have been numerous studies that focus on the demographic trends that will make today's nursing shortage more severe and longer lasting than previous shortages," says Carla Perrotta, senior director of Kelly Healthcare Resources, a business unit of Kelly Services. "But the fact of the matter is that we have a chronic problem that these demographic trends disguise. What we are seeing is not so much a nursing shortage as it is a management shortage."

"Until we stop treating the symptoms and start treating the disease, the healthcare community will have limited success in solving this crisis," she continues. "If the healthcare industry really wants to be assured of an adequate supply of nurses, working conditions must improve, image must be enhanced, policies and regulations must be revamped and more authority, autonomy and respect must be forthcoming."

THE SUPPLY SHRINKS . . .

That is not to say the demographic issues are unimportant or easily dismissed. Indeed, they compound many of the systemic issues that contribute to the shortage.

The American Hospital Association (AHA) says there are 126,000 nursing positions currently unfilled in hospitals across the country. The average nurse vacancy rate was measured at 10.2 percent with the highest rates found in critical care units (14.6 percent) and medical-surgical care (14.1 percent). In increasing numbers, would-be nurses are bypassing nursing careers in favor of other more attractive opportunities.

The shortage of registered nurses is already having ill effects on the U.S. healthcare delivery system: 90 percent of long-term care organizations lack sufficient nurse staffing to provide even the most basic of care, and many home healthcare agencies are being forced to refuse new admissions as a result of inadequate staffing.

In a recent study conducted on behalf of the AHA, 38 percent of the respondents reported that the nursing shortage has caused emergency department overcrowding in their hospitals; 25 percent reported a diversion of emergency patients; 23 percent reported a reduction in the number of staffed beds; 17 percent reported a discontinuation of programs and services; and 10 percent reported cancellations of elective surgeries.

The fact that there are not enough nurses to meet demand means additional demands on existing nurses—adding stress, frustration and ultimately high burnout rates. The American Organization of Nurse Executives reports the average registered nurse (RN) turnover rate in acute care hospitals was 21.3 percent.

Those that stay are working harder and longer. Nurses work an extra eight-and-a-half weeks of overtime per year, according to the Service Employees International Union.

Even more alarming, the Joint Commission on Accreditation of Healthcare Organizations this summer blamed the shortage of nurses for thousands of deaths caused by problems such as medication errors, patient falls and hospital infections.

"Not surprisingly, those organizations that are better able to retain their nurses fare better on quality measures," says Perrotta. "Low turnover hospitalsóat rates under 12 percent—had a lower risk of death or injury as well as lower lengths-of-stay compared to hospitals with turnover rates that exceeded 22 percent."

. . . AS THE DEMANDS INCREASE

The current nursing shortage comes at a time when patient acuity is higher and treatment options more complex. But what is already a bad situation only threatens to worsen. The baby boom generation—all 78 million of them—are aging. More so than generations before them, baby boomers in their old age will have access to scientific advances and technologies that will help them live longer—if the healthcare delivery system can deliver.

Employment in hospitals, the largest sector, is expected to grow more slowly than in other healthcare sectors. While the intensity of nursing care is likely to increase, requiring more nurses per patient, the number of inpatients (those who remain in the hospital for more than 24 hours) is not likely to increase much.

Patients are being discharged earlier and more procedures are being done on an outpatient basis, both in and outside hospitals. However, rapid growth is expected in hospital outpatient facilities, such as those providing same-day surgery, rehabilitation and chemotherapy.

An increasing proportion of sophisticated procedures, which once were performed only in hospitals, are being performed in physicians' offices and clinics, including ambulatory surgicenters and emergency medical centers. Accordingly, employment is expected to grow faster than average in these places as healthcare, in general, expands.

Home healthcare also is expected to grow rapidly. This is in response to the growing number of older persons with functional disabilities, consumer preference for care in the home, and technological advances that make it possible to bring increasingly complex treatments into the home. The type of care demanded will require nurses who are able to perform complex procedures.

In a related vein, employment opportunities in nursing homes are expected to grow faster than average due to increases in the number of elderly, many of whom require long-term care. In addition, the financial pressure on hospitals to discharge patients as soon as possible should produce more nursing home admissions. Growth in units that provide specialized long-term rehabilitation for stroke and head injury patients, or that treat Alzheimer's victims, also will increase employment.

Given this additional demand for healthcare services, it is estimated that by 2020, there will be at least 400,000 fewer nurses available to provide care than will be needed.

. . . AND MORE NURSES ARE LEAVING

Aging right along with their baby boomer peers are nurses themselves. The average age of a working registered nurse today is 43.3, and that average age is increasing at a rate more than twice that of all other workforces in this country. Only 12 percent of registered nurses in the workforce are under the age of 30, a decline of 41 percent compared to a one percent decline for all other occupations.

Recent figures show that 40 percent of nurses working in hospitals reported being dissatisfied with their jobs. The study indicates that one out of every three hospital nurses under the age of 30 are planning to leave their current job in the next year.

That attrition is driving up the average age of nurses. By 2010, it is projected that the average age will be 50. As growing numbers of nurses reach retirement, far too few are coming forward to fill their ranks.

For several years, enrollment in schools of nursing has been decreasing. According to the American Association of Colleges of Nursing, enrollments in bachelor's degree programs have declined for five years.

SEARCH FOR THE CURE

Just as the reasons behind the nursing epidemic involve a number of complex demographic, cultural, political and systemic issues, Perrotta believes the solutions to create true and sustainable progress to attracting and retaining quality nurses will demand a fundamental change in the way nurses are treated by the healthcare delivery system.

"Employers are going to have to deploy a wide array of innovative recruiting strategies to attract people into the profession," she says. "Already we are witnessing an increase in strategies such as sign-on bonuses, relocation coverage or new premium packages."

Just as important as attracting new people to the profession is building a culture of retention within the workplace, according to Perrotta. "Effective organizations genuinely care about their people, invest in their training, nurture their development, empower them to make decisions and reward them for their efforts. Organizations that understand what people are seeking from the work environment have a better chance to recruit and retain top talent."

The keys to retaining nurses include:

• Recognizing personal needs. Part of that cultural shift will be to treat nurses as individuals, with individual needs and concerns. The healthcare industry must understand that nurses enter the profession in search of meaningful work that allows them to tap their knowledge and skills in ways that provide patients with comprehensive and professional care. They are spurning the traditional task orientation model that conventionally has governed their performance. Traditional hierarchal work models—long an irritantóshould give way to a more collaborative environment that fosters continuity of care.

• Boosting pay. The U.S. Department of Labor reports that median annual earnings of registered nurses were $44,840 in 2000. The middle 50 percent earned between $37,870 and $54,000. The lowest 10 percent earned less than $31,890, and the highest 10 percent earned more than $64,360. Median annual earnings in the industries employing the largest numbers of registered nurses in 2000 were as follows:

Personnel supply services—$46,860
Hospitals—$45,780
Home healthcare services—$43,640
Offices and clinics of medical doctors—$43,480
Nursing and personal care facilities—$41,330

While actual earnings for RNs increased steadily from 1983 through 2000, "real" earnings—the amount available after adjusting for inflation—have been relatively flat since 1991. Thus, on average, RNs have seen no increase in purchasing power over the last nine years.

Furthermore, a good portion of the wage growth for nurses occurs early in their careers, then tapers off with time. In 2000, RNs who graduated five years earlier typically earned wages 15 to 17 percent higher than those newly entering the field, but only one to three percent less than nurses who graduated 15 to 20 years earlier.

"As their potential for increased earnings diminishes over time, staff nurses may be motivated to leave to pursue careers outside the profession," concedes Perrotta.

• Improving the work place. Nurses don't have near the support or resources to do their jobs effectively. In fact, the inadequate supply of nurses—combined with budget cuts, continued reorganization and paperwork requirements—puts a huge strain on nurses. On top of that, the healthcare industry is seeing an exodus of key staff, including various allied health professionals, secretaries and support staff. That means nurses are forced to take on more assignments that take them away from the very thing that makes their jobs rewardingóthe direct interaction with the patient.

While nurses are called upon to do more, they still must work under antiquated schedules that require evening, night and weekend shifts. "Healthcare employers must nurture their nursing staff by offering flexibility in scheduling, increased time off and sabbaticals," says Perrotta.

In addition, nursing is physically demanding (requiring a lot of patient movements) and potentially dangerous (with increased exposure to infectious diseases). To keep nurses engaged, facilities are going to have to look at redesigning the way they care for patients to lessen the physical demands of the job. That includes anything from hoists to help with lifting a patient, to retractable needles that protect against unintentional pricks. At the same time, they will have to look to infuse new technology to eliminate some paperwork requirements.

• Creating opportunities for advancement. While not all nurses aspire to management or to the responsibilities of a head nurse, they are looking for opportunities to grow personally and professionally. Some of these needs can be met in more aggressive pay schedules and shift priorities.

But it can't end there. Progressive hospitals are investing in intensive training programs for nurses in areas such as the operating room, critical care and neonatal care units. This helps to retain nurses who are looking for a transfer opportunity, as well as to recruit new staff. It also builds a career development path for staff. Beyond skill development, progressive employers are investing in personal development training in areas such as communication, team building, leadership, conflict resolution and delegation.

Additional advancement opportunities that many nurses find attractive include getting involved in professional associations, assisting in training or mentoring, sitting on employee advisory committees, participating in community service or being ambassadors to schools, trade fairs and service organizations.

• Treating nurses with respect. Because they are the closest to the patient, nurses need to be involved in creating, coordinating and delivering care in any setting. But until recently, nurses were rarely included in such decisions. When they do get involved and are empowered to make decisions, they tend to find the work environment more rewarding and fulfilling.

• Enhancing image. Traditionally, the nursing profession ranks very high as a trusted profession in the U.S.—above physicians and other healthcare workers, despite the lack of knowledge about what nurses do.

However, many in the healthcare field, and within the nursing community itself, don't share that same perception. Like other predominantly female professions, nursing has remained undervalued and underappreciated. Often, the role of a nurse is defined in relation to the physician, as nothing more than a handmaiden there at his or her beck and call.

"As some of the other systematic improvements bear fruit, nurses should rekindle the pride and excitement of what attracted them to the profession in the first place," hopes Perrotta. "Nurses have the responsibility to share, and also shape, the impression that others have about the profession."

• Eliminating regulatory and policy frustrations. Regardless of the setting, nurses complain about the amount and complexity of paperwork needed to comply with regulatory and insurance requirements. For every hour that nurses spend with patients, they are spending at least an hour on administrative duties.

"Although many believe that technology will solve this problem, those who are using electronic documentation systems report that they are not necessarily spending less time documenting," says Perrotta.

"Healthcare systems need to champion the causes of nurses, looking for ways to improve processes and relieve the administrative burden that has become a huge source of frustration. Front line staff should drive this process with consultation from internal experts in patient documentation, risk management and reimbursement," she says.

LOOKING AT THE BROADER, SOCIETAL CONTEXT

As the healthcare industry begins to recognize and accepts some of the responsibility for creating an inhospitable environment, and follows that up with some fundamental reforms, then we, as a society, can start looking for ways to build and develop the applicant pool. Following are some of the traditional remedies:

• Mandated ratios. As the ratio of patients to nurses continues to climb in hospital settings, several states have responded with initiatives that mandate a certain ratio. While on the surface, this would be a step in the right direction, the quality of care and positive outcomes cannot be guaranteed by artificial ratios. "This is a short-term fix that once again does not address many of the systemic issues exacerbating the shortage," says Perrotta. "You can mandate ratios, but you cannot mandate quality of care. Nor can you mandate an enlightened healthcare environment."

• Foreign nurses. A recruitment strategy that has been successful in the past, and is being used again, is the employment of foreign nurses. However, many other countries are also experiencing a shortage of nurses, therefore this strategy may not help. In fact, many are predicting that there is an emerging global shortage of nurses.

• Licensing standards. State boards of nursing need to review policies and procedures to ensure they are still relevant. However, the healthcare industry "must also resist the pressure to lower licensure standards to increase the number of graduate nurses," says Perrotta. "This would be a mistake. We, as a community, are responsible for protecting the public from unsafe, illegal or unethical practice. During times of shortage and stress, the potential for unsafe practice may be heightened."

• Recruitment of students. The U.S. Department of Health and Human Services National Center For Health Workforce Analysis, in a study released this past summer, shows that after growing steadily during the first half of the 1990s the number of new RN graduates fell annually in the last half of the decade, resulting in 26 percent fewer RN graduates in 2000 than in 1995. Declines were seen across all degree programs—diploma, associate degree and baccalaureate. The decrease in diploma graduates continues a trend driven in the past few decades by the closing of hospital-based diploma programs. In contrast, the declines in associate degree and baccalaureate graduates are a more recent phenomenon, having occurred only since the mid1990s.

• A faculty shortage. According to a survey by the American Association of Colleges of Nursing, more than a third (38.8 percent) of schools pointed to faculty shortages as a reason for not accepting all qualified applicants into entry-level baccalaureate programs. Unfilled faculty positions, resignations, projected retirements and the shortage of students being prepared for the faculty role, pose a threat to the nursing education workforce over the next five years.

THE BOTTOM LINE

Without immediate and fundamental changes in the healthcare system in which the rhetoric matches the reality, the nursing shortage has the potential of reaching epidemic proportions, compromising the quality of care and influencing lifestyle choices.

Fortunately, the general public is starting to recognize the extent of the problem and is demanding accountability from their healthcare community.

"Nursing can be an attractive profession," concludes Perrotta. "This is a kind of profession where you can make a difference and the personal satisfaction and fulfillment can be extremely rewarding. But it has to occur in the context of something that is positive."

Kelly Healthcare Resources services all levels of healthcare specialists and professionals in the following disciplines: medical laboratory, pharmacy and pharmacology, RN & LVN, medical assistants, MRI/CT and X-ray technicians, healthcare billing/coding, medical records, utilization and chart review, case management, occupational health and physical therapy. Kelly Healthcare Resources staffing solutions are designed to meet the varied needs of its clients, offering short-term assignments and full-time placement. For more information visit www.kellyhealthcare.com.