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Nurses: Are Physicians Losing Their Better Halves?

The New Physician November 2001
The ranks of nurses are thinning, and although recent congressional action may help initially boost the numbers, the crisis is deeply rooted in other, more complex factors. Is there anything you can do to help?


Like many other medical school graduates, Dr. Michael Greenberg’s transformation from green medical student to full-fledged physician took a bit of patience and practice. Some of his mentors were experienced physicians, but frequently a helping hand came from the nursing staff. In fact, says Greenberg, now an Illinois-based dermatologist, there were as many nurses as physicians who helped him navigate through that difficult intern year.


Places like the newborn and pediatric intensive care units were especially overwhelming for him. “But I admitted my ignorance and asked the nurses for help,” he says. “And the support I got from them was wonderful.”


Because nurses spend so much time with patients, Greenberg found them to be an invaluable resource. They taught him medical techniques, such as suturing, and how to hold a baby. He asked for their advice and assistance in each area he rotated through, and he says they never failed to supply answers or offer their support.


But now, Greenberg worries about the newly minted physicians who are writing D.O. or M.D. next to their names for the first time. Will there be a friendly nurse to help them in the middle of the night or to teach them the finer points of patient care? Perhaps not. According to recent studies, nurses are becoming few and far between, vanishing from hospitals at an alarming rate. In fact, if the trend continues, many in the medical field wonder if there will be enough nurses to provide quality patient care.


WHERE HAVE ALL THE NURSES GONE?


Registered nurses (R.N.s) make up the largest segment of the health-care work force. According to the Department of Health and Human Services’ (HHS) “National Sample Survey of Registered Nurses,” there were an estimated 2,696,540 people licensed to practice nursing in the United States in 2000. Of the total licensed R.N. population, approximately 58.5 percent were working full time, about a quarter were working part time, and 18.3 percent were no longer employed in the profession. Finally, about 60 percent of nurses worked in hospitals, a number that has remained fairly stable over the past decade. The remaining R.N.s were employed in such diverse settings as state and local health departments, community health centers, schools, and visiting nursing and occupational services.


Between 1996 and 2000, the number of R.N.s increased by 137,666, or 5.4 percent. This may sound encouraging, but the numbers are deceiving. It was actually the lowest increase reported, compared to previous HHS surveys. This small increment does not begin to supply the manpower needed to replace retiring nurses, those changing professions or those moving on to higher education and out of patient care.


An analysis conducted by First Consulting Group in February 2002 reported some sobering facts. Nationally, hospitals are averaging a 13 percent vacancy rate for nursing staff. Shortages higher than 20 percent have been reported by more than one in seven hospitals. And to add salt to the wound, the problem shows no signs of abating. If anything, it’s worsening, as 60 percent of the surveyed health-care facilities reported their vacancy rates have increased since 1999.


Since 90 percent of nurses are women, changes in opportunities and traditional roles have had a major impact on the field. And compared to many other opportunities, nursing is frequently seen as less than desirable.


“What other job do you have to work all shifts, work holidays, feel lucky if you can sit down for five minutes, have to wait to go to the bathroom? Not many jobs make you do this anymore,” says Robert Knees Jr., R.N., the director of emergency services at Stevens Hospital in Edmonds, Washington. “Not many, that’s for sure.”


Jobs Rated Almanac 2001 puts nursing in 137th place, out of 250 professions. It’s facing stiff competition from better paying and more prestigious professions when it comes to attracting newcomers to its ranks. Hospital jobs have also become less appealing to experienced nurses who are weary of unsafe patient loads, mandatory overtime and stagnant pay. And with better options abounding, both inside and out of health care, increasing numbers of R.N.s are opting to leave hospital work or bypass it completely.


Despite these difficulties, though, the field is still well respected. Gallup surveys report the public highly regards nurses, believing that it’s a noble profession and that nurses adhere to extremely high standards of honesty and ethics—so that doesn’t seem to be the trouble.


“Our image is great, according to the latest poll. But that still doesn’t convince the public to become nurses,” Knees says.


Baby boomers, big business and aging staff
A decline in numbers is nothing new to this field. Since World War II, nursing has experienced peaks and ebbs. The shortage of nurses in the armed forces was so critical during the war that Congress authorized a nursing draft. But before it could be activated, Germany surrendered, and a few months later the atomic bomb was dropped on Japan, effectively bringing the war to a close. Aside from a wartime emergency, however, past shortages tended to be either cyclical, artificially created by managed-care cutbacks, regional or confined to certain specialty areas.


The current nursing shortage is different, though, in that it’s nationwide, affects most health-care sectors and specialties, and appears to be here for the long haul. Its roots are not just based in job dissatisfaction or the prospect of a more lucrative and safer career choice. Instead, they’re intertwined with numerous other demographics. Many experts say this combination of factors makes it unlikely that the crisis will reverse itself anytime soon.


One problem: retiring R.N.s. “There is a large number of nurses reaching age 55 and above by 2008,” says Mary Foley, R.N., past president of the American Nurses Association (ANA). “Retirement is going up and numbers of enrollees in all schools are going down.”


According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the average age of an R.N. is 43.3, with only 12 percent of nurses younger than 30. Figure the math, Foley says, and the results are staggering. According to the HHS survey, about half of all R.N.s will be approaching retirement age within the next 15 years, and current enrollment in nursing schools will not be able to replace them. R.N.s are entering the profession at an older age or as a second career and will have fewer years to spend in nursing. Traditionally, nurses entered the field at about age 21 and spent 40 years on the job.


Another problem: rising patient numbers. As bad luck would have it, just as a large number of nurses will be heading for retirement, the first wave of 78 million baby boomers will hit age 65 and enroll in Medicare. An aging population generally increases the demands on the health-care system, as seniors are more susceptible to chronic diseases. It is predicted that by the year 2020, the number of R.N.s will be 20 percent below what will be needed.


The current nursing shortage is not restricted to the United States, however. Shortages are being reported in Canada, the Philippines, Australia, Western Europe, Africa and South America as well. For example, in Canada, a nation where nurses have been aggressively recruited by American hospitals and registries, 14,000 of its 81,000 nurses will be retiring by 2004.


“There has been a perpetual roller coaster of problems with nursing supply and demand—some places may be laying off, for example, but yet there’s plenty of temporary work,” Foley says. “And specialty units may be in need, but entry nurses weren’t. I don’t think any of us in this country have done a very good job in effectively planning a sustained supply for the current and future demands for health care.”


Cost containment and managed care lay at the roots of the problem. In fact, many say the shortage can be considered the beginning of a climax of a largely self-inflicted industry wound. In the mid-1990s, nurses faced huge job layoffs as managed care took hold.


Going back a few decades, nurses basically subsidized the industry. Salaries were rock bottom and, in many cases, barely above minimum wage. Come the 1970s and ’80s, women left nursing for other career choices. Those who remained also began to speak up for the first time. Some even went out on strike for better wages and benefits. A victorious nurses’ strike at Washington Hospital Center in Washington, D.C., in 1981 forced other area hospitals to increase their wages in order to be competitive. And for the first time, R.N.s nationwide were finally beginning to earn a decent wage. Plus after years of decline, freshmen enrollment in nursing programs began to rise, peaking in 1992. Then came the fall.


“In the middle of the ’90s, the hospital industry said we have 300,000 too many nurses, and we’re going to be laying them off,” Foley says. “What they were doing was using their economic calculations of how much they wanted to cut the budget and not looking at what people needed. It was absolutely illogical….”


“Restructuring” consultants were hired by many hospitals to “re-engineer” health care in order to increase profit margin. R.N.s and other skilled workers were downsized, and as a result, tens of thousands lost their jobs. In 1997, 5 percent of California R.N.s were laid off in one year alone.


“We saw complication rates go up and patient-satisfaction go down,” Foley says. “So the current nursing shortage is a function of an industry that failed to invest adequately in nursing, and they forgot to invest in the basic care that they’re responsible for—they buy the equipment, they buy the drugs, they get the technology because you have to stay competitive, but they forgot the people who provide the care.”


Conditions went from bad to worse, and R.N.s feared for the safety of their patients as well as their own liability. Frustrated with the system, many threw in the towel and left. The consulting firm William Mercer conducted a study in 1999 that showed a 17 percent R.N. turnover rate, with almost half of them naming staffing and workload as their reasons for leaving.


As nurses were abandoning hospitals, enrollment in nursing schools plummeted. From 1995 to 1998, it fell by 20 percent. In response, schools cut back their nursing programs, and some universities eliminated their undergraduate nursing degree offerings completely. It became near impossible for entry-level nurses to find employment, and hospitals reduced their numbers of training programs and got rid of clinical specialists. When training courses disappeared for intensive care, the OR, emergency, and labor and delivery, those areas slowly but surely began to show the first signs of vacancy problems. And now, specialty-nursing areas face the most critical shortages with few prospects of getting experienced nurses to fill the empty slots.


FINDING MORE NURSES


The industry is now scrambling to fill the void. Recruiters are busy attending nursing job fairs, and hospitals are trying to entice nurses with sign-on bonuses—some of the offers have reached $14,000. Johnson & Johnson, in conjunction with health-care leaders and nursing organizations, launched a glitzy, nationwide media campaign—television and print advertisements and a Web site—aimed at convincing the public that being a nurse is a good career choice.


The government has taken some action too. President Bush recently signed the Nurse Reinvestment Act, which will provide scholarships to baccalaureate nursing students, assist already working nurses in furthering their education and support partnerships between nursing schools and practice settings. Kathleen Long, R.N., president of the American Association of Colleges of Nursing, applauds the act, as does Rep. Lois Capps, R.N. (D-Calif.), who helped push the measure through Congress.


But representatives of two-year degree programs say the law overlooks them and the needs of their students. Others say that because the scholarships will work similarly to how the National Health Service Corps program functions—offering financial assistance if the students agree to work in shortage areas after graduation—there are no guarantees that the nurses will stay in the needy areas. Plus, Congress has yet to specify the funding for the measures.


And to complicate matters, nursing faces a shortage of qualified instructors. Even if enough students were to apply to nursing schools, many could be turned down due to a lack of skilled teachers. In February 2002, the Southern Regional Education Board documented a serious nursing faculty shortage in 16 states and the District of Columbia. The combination of vacant slots plus newly budgeted positions showed a vacancy rate of 12 percent. A survey by the same group in May 2001 disclosed that 144 faculty members retired in that academic year, and more than 550 had already resigned or were expected to resign within the next two years.


The outlook for replacements is not altogether optimistic either. During the 2000–2001 academic year, enrollment in nursing master’s and doctoral degree programs was down 3 percent and 11.1 percent, respectively. The average age of nursing faculty is 53.5 years old. And nurses with advanced degrees, or even just a baccalaureate, have other opportunities available to them, says Anne Marie Brooks, R.N., the dean of Catholic University of America’s School of Nursing. “They can be practitioners, nurse anesthetists or go into administration. Teaching is just one option, and for many nurses, not the most desirable one,” she says.


The Reinvestment Act addresses some of this by including a nurse faculty loan program, granting scholarships to students who agree to teach after graduation. However, like other areas of the new law, it lacks a specification for how the scholarships will be funded, and some worry if nurses in the faculty program will remain teachers once their obligations are up.


NURSE RETENTION


But new laws and programs aside, if working conditions don’t change, nurses aren’t going to stay on the job.


A study published in the May–June 2001 issue of Health Affairs reports that more than 40 percent of hospital nurses are dissatisfied with their jobs. The study goes on to say that one of every three hospital nurses under the age of 30 is planning to leave her current job within the next year. Nurses complain of a lack of training, mandatory overtime and unsafe patient loads.


The results of an Ohio Nurses Association survey conducted in 1999 and 2000 reflect just how much the system may be broken. Eighty-four percent of the respondents believed their patient loads have grown in the last few years, and half of them stated that they were “frightened for their patients.” Nearly one-third reported an increase in medication errors, and 85.5 percent said patient acuity has increased. The nurses concluded that their working conditions are taking a toll on them, and the quality of patient care in Ohio has been jeopardized.


In fact, a recent study conducted by JCAHO found that the low nurse staffing levels have contributed to 24 percent of the 1,609 patient cases resulting in death, injury or permanent loss of function that were reported to the accrediting organization since 1997.


Add the headaches of managed care to unsafe patient loads. Nurses are obligated to spend a great deal of time in nonpatient care, Knees says. “They now have to learn about Medicare coding and all of the regulations. Nurses have to know what to write based on what you can charge patients. The paperwork is horrible, and they are spending more time on paperwork than patient care.” And ultimately, he says, nurses give up on the paperwork because they want to do patient care. Then, Knees says, health-care facilities suffer financially, because they don’t bill for everything.


While physician–nurse relationships have improved over the years, the quality of their daily interactions with physicians also greatly impacts nurses’ job satisfaction, according to a study by VHA Inc., a national health-care alliance representing 25 percent of the nation’s community hospitals. VHA found that disruptive physician behavior, which includes any inappropriate behavior, confrontation or conflict, ranging from verbal abuse to physical and sexual harassment, is still alive and well. Ninety-two percent of the study’s respondents reported they had witnessed at least one instance of disruptive physician behavior. The institution’s response to the behavior, as well as the episode itself, is a contributing factor in nurses’ morale and their decisions to leave their positions.


Finally, nurses say they feel they often don’t get any support from nursing management or their state nursing boards. Nurses who have protested unsafe working conditions, complained about the quality of patient care, or refused assignments that put their licenses in jeopardy are often disciplined or even fired.


Barry Adams, an R.N. who blew the whistle on unsafe practices in his Massachusetts facility in 1996 and was summarily dismissed, spent the next few years fighting his wrongful termination and the Massachusetts Board of Nursing, which had refused to take action on his complaints. He ultimately won and was ordered reinstated with back pay. He declined reinstatement, worked two years outside of the hospital setting and left nursing for good in 1999.


“My experience in health care taught me not only is there no support for direct-care providers—nurses in particular—but the current system is organized in such a way that it renders practicing clinicians powerless to change that which directly prevents them from providing what vulnerable patients need to achieve good health-care outcomes….


“After battling the system for four years, and seeing what nurses and physicians are actually up against, I felt I am no longer willing to take the risks involved for myself and the patients for which I was legally and ethically responsible. And the numbers show that I am in no way alone in walking away from a comfortable, midlevel salary. Working as a nurse is, for many, futile work,” he says.


Greenberg is a little more optimistic. “I would encourage young people to become nurses and doctors, despite all of the negativity,” he says. “I encourage them to do this if they’re called from their heart. Young doctors, young nurses—it’s a spiritual calling. The only way things are going to change is if we get people coming into the system whose hearts are in the right places and who are willing to speak up to change it. The doctor–nurse–patient relationship is sacred; it’s not a commodity. It’s about compassion and love, the mystery of healing.”


The year 2010 has been designated as when the crisis will peak. Will there be a nurse in the house?
While pursuing a career as a medical and health writer, Roxanne Nelson worked as a registered nurse for 12 years. She lives in Seattle, Washington.