- The Washington Times - Sunday, December 15, 2002

Hospitals competing for registered nurses amid a nationwide shortage are offering inducements ranging from signing bonuses some as high as $15,000 on top of $60,000 starting salaries to free child care and a free continuing education.
One advertisement in a nursing trade publication offered a new car for any nurse who agreed to work for at least two years.
Patricia S. Yoder-Wise, first vice president of the American Nurses Association, said such an enticement isn't a wise investment for hospitals.
"When the two years are up, the nurse will take the car, leave the hospital" and find another job with better perks, Ms. Yoder-Wise said.
Still, she recognizes that hospitals are desperate to recruit and retain nurses. In fact, some hospitals have begun offering $1,000 to $3,000 "retention bonuses."
"The nursing shortage is pretty dramatic, it's probably the worst we've ever seen," and no one expects it to ease anytime soon, Ms. Yoder-Wise said.
National surveys, including one by the American Hospital Association, indicate hospitals are averaging 11 percent to 14 percent vacancy rates in nursing positions, about 120,000 vacancies nationwide. The federal government predicts the number of vacancies will surpass 800,000 by 2020.
"The projected shortage in 2020 results from a projected 40 percent increase in demand between 2000 and 2020, compared to a projected 6 percent growth in supply," said a report released last summer by various agencies of the U.S. Department of Health and Human Services.
Nurses and physicians say hospital nurse staffing levels are already inadequate for safe and effective care, says a University of Pennsylvania study recently published in the Journal of the American Medical Association.
It found that the "difference from 4 to 6 patients and from 4 to 8 patients per nurse would be accompanied by 14 percent and 31 percent increases in mortality, respectively."


Burnout builds
Key factors in the shortfall, health officials say, are the aging of the nursing population and professional "burnout." Many nurses are reaching retirement, as are faculty members in nursing schools, and not enough people are replacing them. Enrollments in nursing schools are down, and some schools are closing.
"Hospital nursing is heavy sledding. It's very hard work. It's a 24/7 operation," said Molly Billingsley, assistant vice president for operations support at Georgetown University Hospital.
"Nurses have to give up parts of their lives that lawyers, accountants and those in other professions don't have to," said Mrs. Billingsley, whose division is responsible for nurse recruiting.
In New York, thousands of registered nurses don't use their licenses because of working conditions, said Anne Schott, spokeswoman for the New York State Nurses Association.
Miss Schott said nurse retention would improve greatly if hospitals didn't overwork the ones they had, especially by forcing them to work overtime shifts without prior notification.
"The use of overtime as a staffing shortage 'solution' is pervasive. On average, nurses work an extra eight-and-a-half weeks of overtime per year," said a report by the Joint Commission on Accreditation of Healthcare Organizations.
Fed up with overtime and night and weekend work, many nurses have left the rigors of direct patient care services in hospitals and nursing homes for less-demanding nursing career options.


Leaving the hospital
Seeking "more regular hours, many nurses now work for managed care plans and insurance companies, pharmaceutical firms, health care technology and medical device vendors, and consulting firms, among others," said the joint commission report released in September.
"Years ago, most women [looking for jobs outside the home] either became teachers or nurses, but today they have so many other options," said Gaurdia Banister, vice president of nursing at the 408-bed Providence Hospital in Northeast Washington.
Estimates vary on the extent of the shortage.
In addition to the HHS report, the Joint Commission on Accreditation of Healthcare Organizations, which found 126,000 vacant nursing positions in U.S. hospitals last year, predicted that number could top 400,000 by 2020.
The American Hospital Association also foresees a nursing shortfall of that magnitude over the next two decades. The accounting firm of Ernst & Young expects the nursing shortage in hospitals and clinics to exceed a half-million by 2020.
University of Pennsylvania researcher Linda Aiken and other authors of the JAMA study have concluded that overworked nurses contribute to hospital fatalities.
"After adjusting for patient and hospital characteristics each additional patient [in the average nurse's workload] was associated with a 7 percent increase in the likelihood of [a patients] dying within 30 days of admission and a 7 percent increase in the odds of failure-torescue," meaning a patient who dies after developing complications, the authors wrote.
Their study also showed each additional patient a nurse was assigned was related to a 23 percent "increase in the odds of burnout and a 15 percent increase in the odds of job dissatisfaction."


Workload a villain
"The shortage of hospital nurses may be linked to unrealistic nurse workloads. Forty percent of hospital nurses have burnout levels that exceed the norms of health care workers," Ms. Aiken and her research colleagues, most of whom are nurses, wrote in the JAMA.
"Job dissatisfaction among hospital workers is four times greater than the average for all U.S. workers, and 1 in 5 hospital nurses report that they intend to leave their current jobs within a year."
Ironically, the demands on hospital nurses to provide direct care are becoming greater as the number of nurses becomes scarcer.
"Hospitals have become critical-care units. You don't go to a hospital today unless you are critically ill," said Justine Medina, practice and research director for the 65,000-member American Association of Critical Care Nurses based in California.
The JAMA study said, "Registered nurses constitute an around-the-clock surveillance system in hospitals for early detection and prompt intervention when patients' conditions deteriorate."
Ms. Banister says the job is more stressful than ever.
"Patients are much more complex now, and they stay in hospitals for shorter periods of time," which forces nurses to provide the proper care in a shorter time frame, she said.
What's more, many nurses and nursing school faculty members are reaching retirement age.
The average age of a registered nurse is 45, and the average age of a critical-care nurse is 47, Ms. Medina said. The average nursing school faculty member is in her "early 50s," Ms. Yoder-Wise said.


Graying nation
An aging population will aggravate the problem. The ranks of senior citizens in need of medical attention will rise as the nursing shortage hits its peak.
"The United States, of course, is an aging country. Over the next four or five years, you will see a dramatic change in the number of people turning 65," Ms. Yoder-Wise said.
The number of Americans 65 or older, estimated at close to 35 million in 2000, should reach 40 million in 2010, 54 million in 2020 and 70 million in 2030, the National Council on the Aging reports.
With the continued nurse shortage and graying of America, several nursing unions are trying to cash in.
"In contract talks, we've been pushing for higher salaries. At major medical centers in New York, such as Columbia-Presbyterian Hospital, we're seeing starting salaries of $60,000," Miss Schott said.
The 2000 National Sample Survey of Registered Nurses reports that the average pay for a hospital staff nurse is $42,133.
"Salaries have not been rising as fast as demand [for nurses]," said Ms. Medina, who noted that the biggest losers have been experienced nurses, whose pay often is not substantially above that of starting nurses.
Miss Schott said many hospitals are reluctant to increase nurses' pay significantly.
While pay is an issue, she said: "Most experienced nurses are primarily concerned about staffing levels. If you run an understaffed unit, patients' lives are at risk."
Miss Schott noted that is especially true in trauma and intensive care units, which are among those experiencing the greatest shortages.


Swapping specialties
In such specialized units, Miss Schott said, the ideal ratio between nurse and patients is 1-to-1 or 1-to-2. But because of the lack of personnel, she said, actual patient-to-nurse ratios may be higher.
In some cases, Miss Schott said, nurses are transferred to other units that require specialized care they are not equipped to offer.
"No one would send an obstetrician to operate on an orthopedic patient, and nurses should not be sent to do jobs for which they don't have proper training," she said.
Ms. Medina of the American Association of Critical Care Nurses said the group has concerns about fixed patient-nurse ratios, such as those called for under new California legislation. She said those judgments should be based on a patient's needs and the "education and competency" of the nurse.
The good news, the study in the JAMA said, is that California officials rejected "ratios favored by hospital stakeholder groups of 10 patients to each nurse on medical and surgical general units in favor of more generous staffing requirements of 5 to 6 patients per nurse."
The Joint Commission report found that six states Maine, Maryland, Minnesota, Oregon, New Jersey and Washington have passed legislation to ban or limit mandatory overtime, but said many others are "actively considering" such legislation.
Ms. Medina said "preliminary data" in a study by University of Pennsylvania researchers show that nurses working 12 to 16 consecutive hours are subject to the same kinds of safety concerns as pilots flying long distances without sufficient rest.
Washington state's law bars nurses from working more than 12 hours in a 24-hour period or more than 80 hours within 14 consecutive days. The New Jersey statute prohibits health care facilities from requiring overtime for nurses except in emergencies.


Cost cutting
Miss Schott traces the origins of the nursing shortage back to the mid-1990s, "when hospitals restructured how to deliver care, their aim being to reduce costs."
She says paying the nursing staff is one of a hospital's major costs. "To cut costs, hospitals started laying off a lot of RNs. And this made the working conditions for those who remained more and more difficult."
As hospitals laid off nurses to cut costs, enrollment in nursing schools started to decline.
The American Association of Colleges of Nursing said enrollment in bachelor's degree programs for nurses fell by 4.6 percent in the autumn of 1999. That was the fifth consecutive drop in five years. In the fall of 2000, enrollment declined by 2.1 percent.
The New York State Nurses Association reported that enrollment in baccalaureate nursing programs in that state fell by 12.3 percent and in two-year associate degree programs by 25.3 percent between 1995 and 1999.
To try to lure more people into nursing careers, Miss Schott said, "hospitals are pairing up with nursing schools and are paying tuitions for both two-year and four-year programs," in exchange for a student's commitment to work at the hospital that pays for their education.
Such support can be substantial. "Tuition at a private school could be $25,000 [a year]. At a state school, it's more like $6,000," Miss Schott said.

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