A medical crisis: Who'll care for your patients?

A severe shortage of RNs has already plunged many hospitals and nursing homes into chaos. And there's no easy fix in sight.

By Neil Chesanow
East Coast Editor

Arkansas is starving for registered nurses. The demand far outstrips the supply, the most experienced nurses are retired or nearing retirement, and Linda C. Hodges, dean of the University of Arkansas for Medical Sciences' College of Nursing, worries that the dearth of new RNs could mean a catastrophic shortage in coming years.

In Connecticut, the state's RNs are taxed to the max, says Mary W. Hickey, executive director of the Connecticut League for Nursing. Local hospitals and nursing homes couldn't handle a sudden influx of patients. "A flu epidemic would overwhelm our health system right now," she says.

New Jersey families are learning that having a relative or private duty nurse at a loved one's bedside 24/7 is a must if they want to assure good care. Since August 1999, the New Jersey Department of Health and Senior Services has fined 14 hospitals—about one in seven—for not having enough nurses on the floors.

Things are no better in California. "We've had hospital patients call 911 just to get someone to answer their light," says Kay McVay, president of the California Nurses Association. "It's a very sad state of affairs."

Where the crisis is most acute

According to the American Nurses Association, the RN population is sparsest in California, Florida, Minnesota, Missouri, Tennessee, and Texas. Atlanta; Columbus, OH; and Denver are among the hardest-hit urban areas, but the problem is spreading nationwide.

What does it mean to you? "The shortage may jeopardize a hospital's ability to provide timely access to nonemergency services," says Dianne Anderson, president of the American Organization of Nurse Executives (AONE). "Some facilities have pared down hospital services, closed beds, put emergency rooms on divert status, delayed elective surgeries, or transferred patients to other hospitals—all for lack of nurses."

Quality of care is plummeting as well. Two out of five RNs who responded to an ANA survey last year said they were so concerned about the care provided in their facilities that they wouldn't recommend them to a family member.

What's worse, starting in 2011 the first of 77 million baby boomers will become eligible for Medicare. By 2020, with geriatric boomers flooding hospitals in record numbers, the RN workforce—at an estimated 2.7 million—will be nearly 20 percent below projected requirements, an article in JAMA reported last year. "There's growing doubt throughout the health care industry that market forces can bring about a timely adjustment," AONE's Anderson warns.

How we got into this mess

Reports of regional nursing shortages emerged about seven years ago, when the Clinton administration was trying to win congressional approval for its health plan and health care costs were soaring at twice the rate of inflation. Hospitals and other health care facilities responded in part by downsizing nursing staffs—which typically consume 20 percent of operating expenses—or substituting less skilled (and less costly) care providers for RNs. At the same time, with managed care restrictions on hospital admissions, inpatients were sicker, requiring more intensive nursing care. Horror stories of bungled care began making newspaper headlines. Connecticut's Hickey allows that 20 percent of an RN's workload can safely be shifted to unlicensed staff in some units. Even so, she adds, 80 percent of the nurses in acute care units and 100 percent in critical care units still need to be RNs, because only RNs are trained in the sophisticated technology used to stabilize and monitor severely ill patients.

Adding fuel to the fire, in 1997 Congress passed the Balanced Budget Act, which slashed Medicare and Medicaid payments to hospitals, nursing homes, and home health care agencies. "BBA eliminated some $700 billion in reimbursements, forcing us to be significantly leaner," says Brandon Melton, vice president of human resources for Catholic Health Initiatives in Denver, which manages 68 hospitals and 50 long-term-care and retirement housing facilities in 22 states. Emergency physician Georges C. Benjamin, secretary of the Maryland State Department of Health and Mental Hygiene, puts it bluntly: "The Balanced Budget Act was a death sentence for the health care industry."

In testimony before the congressional Subcommittee on Aging last February, AONE's Dianne Anderson spoke of a lack of nurses with skills and experience needed for specialty areas of care such as the ER, labor and delivery, OR, and ICU, compounded by a geographic maldistribution of nurses. But nurse executives now maintain the shortage is also one of bodies. "There's an insufficient number of nurses in the workforce as the demand for nursing services increases," Anderson asserts.

"Insufficient" doesn't quite capture how dire the situation has become. "When our facilities can't get nurses to volunteer to work overtime to meet staffing needs, we turn to internal on-call pools," says Catholic Health Initiatives' Melton. "We then look externally to nursing registries and temp agencies. We even try to hire traveling nurses—although that's enormously expensive. But none of this has solved the problem."

One CHI facility, Mercy Medical Center in Des Moines, is down to its final option—"begging," Melton says. Another, St. Vincent's Infirmary Medical Center in Little Rock, is "praying"—but without much hope. Between 1998 and 2000, the number of RN vacancies in Arkansas has increased by 83 percent. In 1998, just over half of Arkansas hospital administrators believed the nursing crisis had grown worse, an American Hospital Association survey found; by 2000, almost everyone thought so.

Why RN vacancies go unfilled

At nearly 2.7 million, the RN population is still the largest group of health care workers. But only about 59 percent work full time, and 18 percent aren't employed in nursing at all, a Department of Health and Human Services survey last year found. Moreover, as the US population continues to expand, age, and increasingly require nursing services, the number of RNs, relative to the number of patients, will continue to plummet, experts predict.

Why? One reason is that much of the RN workforce is nearing retirement age. Within the next 10 years, more than 40 percent of US nurses will be older than 50. The shortage of nurse educators needed to train new RNs will be even more acute. "The average age of nursing faculty nationwide is already over 50," notes Anderson. "All nursing schools now have serious teaching vacancies."

Compounding the problem: Young women—some 95 percent of nurses are female—have more career choices now and aren't entering the field to replace RNs who retire. In 1980, 53 percent of RNs were estimated to be younger than 40, the HHS survey found. In 2000, it was 32 percent. The most significant drop has been in RNs under 35. Their numbers nosedived from 41 percent of the nursing workforce in 1980 to 18 percent in 2000.

In addition, women who graduate from nursing school today are much older than their counterparts of 30 years ago. "They used to be 23. Now they're 33," Hickey observes. This means new RNs will have shorter careers. It also means a lack of RNs in their 20s to work in critical care and emergency departments, which require the stamina of youth. And today's nursing students aren't as strong academically as their forebears. As a result, says Hickey, "nursing programs have very high attrition rates. Enrollments are down. And we haven't made any significant inroads in attracting men to the field." One reason is salaries. "Although wages for nurses are initially attractive, they're not good long term," Hickey notes. When hospital budgets are pared to the bone, there's little money left for salary increases over time.

For nurse educators, the pay is even worse. Faculty with years of experience may earn a paltry $50,000. "You're not really rewarded for being a teacher," says the ANA's Mary Foley. So young women are becoming doctors or computer programmers instead. Those who are already RNs are leaving hospitals to work at insurance companies, schools, and doctors' offices, or something else entirely.

Poor working conditions also drive them away. "Nurses leave the profession because they don't have enough time to spend with patients," says Hickey. "There's so much more regulation. They're inundated with paperwork. They don't like someone else making their decisions about patient care. They're harried by the number of patients in their charge, and by how fast those patients must be processed through the system." The result is high stress and low morale.

Add to that a chronic lack of support personnel—"which is how you get clinical staff dumping the trash," says Maryland's Georges Benjamin. Factor in, too, regular mandatory overtime, which disrupts family life. More than half of RNs have children at home, the HHS survey found.

Moreover, despite their crucial role in health care, many RNs feel undervalued. When budget crunches loom, hospital administrators consider them expendable—or at least they have in the past. Doctors, who are supposed to be their partners in care, are often contemptuous of them. "While some doctors are wonderful with nurses, others are cynical, disparaging, and uncollaborative. They treat nurses as if they don't know anything, and refuse to listen to them—sometimes to their own disadvantage," observes Robert N. Butler, professor of geriatrics and adult development at Mt. Sinai School of Medicine in New York.

All things considered, it's not surprising that young women are saying No, thanks to a nursing career. Or that for many staff nurses, selling real estate or working for an HMO is starting to look pretty good.

Can the nursing crisis be solved?

Forget easy fixes. There aren't any. Last February, the Senate Subcommittee on Aging held a long-overdue hearing, "The nursing shortage and its impact on America's health care delivery system." This was "the first hearing Congress has had in more than a decade on labor supply issues in health care," says the Catholic Health Initiatives' Melton. "There are no significant federal efforts at this point. Things are likely to get a whole lot worse before they get better."

Sen. Tim Hutchinson (R-AR), the subcommittee chairman, is pushing for legislative remedies. "In conjunction with various stakeholders, including all the nursing groups, we're working on broad legislation that we hope to introduce to Congress soon," he says. "It provides additional funding for educational loan repayment, aid to underserved areas, incentives for nurses to work in those areas, career-ladder incentives, and advertising and public relations campaigns to enhance the image of nursing." But in light of President Bush's intent to ask that budgets be slashed for programs that provide child care, prevent child abuse, and train doctors in children's hospitals, some observers are doubtful that he'll show much interest in new programs to attract nurses.

At the state level, beefing up enrollment in nursing schools, where minority women—and men of any race—are sorely underrepresented, is a priority. "We plan to get kids enthused about nursing again and convince high school guidance counselors to inform students that nursing is a career worth considering," says Maryland's Benjamin. Nursing school scholarships, and tuition breaks for students who want to pursue the higher education needed to become a nurse educator, are also being discussed.

Some hospitals hope to attract nurses by introducing flex-time and day care centers for working mothers. Others are offering signing bonuses or hiring nurses from overseas—although the latter, as Robert Butler points out, could have repercussions abroad. "In Great Britain, for instance, it's appalling that hospitals are poaching nurses from an impoverished country like Ghana, which has a raging AIDS epidemic, persuading them to come to England with better pay and living conditions, while underdeveloped nations become increasingly bereft of nurses," he says.

For Brandon Melton, revamping the image of nursing and creating a family-friendly work environment, while important, won't replace the need for attractive salaries and other monetary incentives. "The federal government must understand that as health care providers, we can't offer competitive pay and benefits if we don't get adequate funding and reimbursement for the work nurses do," he says.

Everyone has a stake in averting disaster—including doctors. "Physicians should be alarmed at the lack of nurses to help them deliver care," says Mary Foley. "In the past, doctors have been silent when nursing cutbacks have occurred. But nurses are eager to partner with doctors and work with them on mutual remedies to assure the public's health. We hope physicians will give us their support."

 

Neil Chesanow. A medical crisis: Who'll care for your patients?. Medical Economics 2001;9:67.