Supply and Demands
What will it take to solve the nursing shortage?
Sitting on a Brighton hilltop like a fortress against disease, the beige brick edifice of St. Elizabeth’s Hospital stands out against the gray March sky. The driveway, which carves a path up to the emergency room and where one might expect to hear the blare of ambulance sirens, is clear and quiet, but motorists heading down Cambridge Street toward the Charles River break the silence by honking their horns in support of the nurses gathered in demonstration at the foot of the hill.
As always, wages and benefits are at issue, but the chief source of labor unrest is another matter—one that doesn’t go away even when a settlement is signed here a few weeks later. Nurses at St. Elizabeth’s, and elsewhere, say that the quality of their work life is suffering, and the health of their patients is in danger. In Massachusetts hospitals, they say, on too many hospital floors, too many patients are looked after by too few nurses.
“I’ll tell you straight out: If you get sick, I fear for your life,” says Rita McMillan, a fiftysomething nurse in St. Elizabeth’s neonatal unit.”There aren’t enough of us to go around.”
On this particular labor grievance, the bosses concur—with the diagnosis, if not the cure. Hospital executives agree that nurses are in short supply. But they say the problem is not just the number of nurses they hire; it is the number of nurses available to be hired. They say that nursing is a profession on the ropes, at a time when the need for nurses—in Massachusetts and across the country —is on the rise.
“It’s always hard to forecast labor markets,” adds David Smith, chief data analyst for the Massachusetts Hospital Association. But that doesn’t stop him from making this one: “Come 2010, 2012, 2015, we’re going to see dramatic reductions of the number of nurses in the workforce unless we do something dramatic, and do it soon.”
Massachusetts has one of the highest numbers of registered nurses, relative to population, in the country. Yet, in 2002, 9.9 percent of budgeted nursing positions were vacant, a level of job openings not seen since 1988 and up from a low of 2 percent in 1996. Last year, the RN vacancy rate dipped slightly, to 8 percent, the first decline in seven years. But that was widely seen as a passing phenomenon—a poor economy forcing older nurses back to work—and one that, in an industry where the average worker is nearly 50 years old, will soon be offset by a wave of retirements. The reality, say those on both sides of the picket lines, is that Massachusetts, like the rest of the nation, is in the midst of a nursing shortage. And with the first members of the baby boom generation approaching 60, the need for nurses will soon be greater than ever.
In Massachusetts, a vital nurse workforce is doubly important: important not only for care but also because of the health care industry’s prominent place in the state’s economy. Any loss of confidence in its internationally renowned hospitals could be as painful to the state as a medical error could be to a patient.
“There might be more nurses per 100,000 people here, but we will still experience the shortage due to the intensity of the health care system in Massachusetts,” says Sharon Gale, president of the Massachusetts Organization of Nurse Executives. “There’s a robust system here, there are a lot of health care institutions throughout the state, and Boston is the mecca of health care delivery. We can’t lose that.”
Compounding the supply problem, a lot of nurses aren’t happy. They believe the only way they will be happy is if there is a legal limit on the number of patients they each are required to care for. Though it may be a legislative blunt instrument, many nurses say that it would guarantee good care for patients and good working conditions for them. But this proposal has hospital administrators squawking—and wondering where they would find the nurses to manage the smaller caseloads.
Health care is big business in Massachusetts, and it needs a lot of hired help. The industry employs 400,000 people overall. As the population ages and demand for medical care rises, even more caregivers will be needed. But no one knows where they will come from. Even today, nursing isn’t the only health care occupation that doesn’t have enough bodies to fill its ranks.
As far back as 2000, a report prepared for the Massachusetts Health Policy Forum warned that the health care industry was in the midst of an”unprecedented” labor crisis: “High vacancy and turnover rates among direct care workers are generating a downward spiral within the state’s health care labor force—creating an instability that threatens the quality and availability of health care services for thousands of people who are ill, elderly, or living with disabilities.”
hospitals, but home care is also suffering.
The demand for doctors (both for general practice and for specialties such as anesthesiology), x-ray technicians, pharmacists, and all manner of home health care aides has also shot up over the past several years, according to a study conducted by the Milken Institute and the New England Healthcare Institute, and no one knows where those needed employees will come from, either. Massachusetts is a national leader in medical training, but between 1997 and 2003 more than half of its medical residents and more than two-thirds of its fellows (post-graduate doctors who get further training before going into practice) left the state after completing their training. The state also lost half its anesthesiologists between 1999 and 2001.
But in any hospital, nurses constitute the largest group of employees and deliver most of the patient care. In the health care chain, nurses are the key link.
“We, as nurses, are the ones who are advocating for our patients,” says Barbara Levin, an orthopedics nurse at Massachusetts General Hospital. “We can make recommendations and communicate to them what the recommendations for their recovery have been. We’re teaching them, and they’re teaching us.”
Nationally, the health care industry is expected to be short more than 800,000 nurses out of 2.8 million needed by the year 2020, according to a study conducted in 2002 by the US Department of Health and Human Services. In Massachusetts, the shortage is projected to be more than 25,000 of the 86,000 needed—or 29 percent, similar to the rest of the nation.
This is not the first time nurses have been in short supply. “There have been cyclical nursing shortages that have been documented over a number of decades,” says the MHA’s Smith. “I came here 16 years ago, and things looked a lot like they do today. We had nurse vacancy rates running around 10 percent, the economy was overheated, and there were problems with ambulance diversions [due to understaffing at emergency rooms]. But within two or three years, the bottom fell out of the economy, and nurse vacancy rates were at 2 or 3 percent.”
The shortage may not fix itself this time around, however, especially in hospitals. In part, that’s because nurses, and prospective nurses, have other options today. According to a study conducted by Peter Buerhaus, a Vanderbilt University School of Nursing professor, registered-nurse employment in non-hospital settings grew throughout the late ’90s. Nurses found they could avoid the stresses of hospital life—and especially the night and evening shifts that are the soft spot in nursing retention—by working for a visiting-nurse agency, a nursing home, or a pharmaceutical or biotechnology company. In addition, the long-term trend of broader career options for women drove down nursing-school enrollments.
“My teacher said to me, when I was a girl, ‘Well, dear, do you want to be a teacher or a nurse?'” says Linda Wells, chief nurse at Emerson Hospital in Concord. “Things have obviously changed, and a lot of the options out there have less stress, fewer hours, and better pay. So, as nurses, we’re competing with all of these other professional opportunities out there for women.”
As a result, the nursing shortage has now spread from hospitals to some of the very industries nurses fled to. Visiting-nurse agencies, for example, told The Boston Globe in December that they had been turning away hundreds of patients per month due to lack of staff.
“The demand is there in the hospitals, and it’s probably the most acute,” says state Sen. Richard Moore, an Uxbridge Democrat who is co-chairman of the Legislature’s Health Care Committee. “But there’s need across the board. We need more school nurses, more visiting nurses for those in their homes, and more for nursing homes and assisted-living facilities.”
Out of proportion
The hospital industry has particular problems drawing nurses to its doors, some of its own making. In the decade of restructuring and consolidation that followed hospital deregulation in 1992 (“Romancing the market,” CW, Winter 2002), nurses bore the brunt of the adjustment to an era of competition and managed care.
“In the ’90s there was much more pressure on hospitals to cut costs and become efficient,” says Dana Beth Weinberg, author of Code Green: Money-Driven Hospitals and the Dismantling of Nursing, which used Boston’s Beth Israel Deaconess Hospital as a case study. “One chief way was to cut the labor force, and primarily they cut nurses. At the same time they did that, they trimmed the length of stay [for patients].”
For nurses, that meant sicker patients to care for. “Even if your caseload stays the same, you’ve lopped off the time of stay in which they don’t need as much care and monitoring,” says Weinberg. “So you have the sickest, neediest patients in the hospital, and there aren’t as many people to take care of them.” The decision to cut staffing levels also cost hospitals”advanced practice” (that is, more-experienced) nurses, who spent less time with patients but were skilled at imparting specialized knowledge to new hires.
“In the 1990s, because those nurses weren’t considered to be providing direct care, they were told, ‘You’re gone. You’re eliminated,’ or they went back to the bedside,” says Julie Shindul-Rothschild, head of community and psychiatric nursing at the Boston College School of Nursing. “Now, some hospitals are hiring those advanced practice nurses back, but the patient loads and the acuity level are such that they don’t have the time to provide the mentoring.”
Some hospital executives admit they have fences to mend with the nursing profession. “Things have gone awry when administrators and doctors have tried to treat nurses like pieceworkers in a factory,” says Paul Levy, chief executive of Beth Israel. “This place did for a while, and that’s what we had to undo.”
Beth Israel was a shambles as recently as three years ago, the byproduct of a tumultuous merger with New England Deaconess, according to Weinberg. But under Levy, the hospital has tried to make amends by taking nursing concerns to the top, with strong chief nurses serving at the executive level. Patient acuity and nurse staffing levels are closely monitored, and nurses are encouraged to come up with their own schedules. Massachusetts General Hospital takes a similar approach.
“If a nursing floor says we need more people, we respond to that,” says Levy. “Part of what we try to do is called shared governance, where nursing staff are meeting with governors on a regular basis and saying, ‘This is what we need.’ My job as CEO is to make sure there’s a good shared process across the hospital.”
The Massachusetts Nurses Association, the union that represents 25 percent of nurses in this state, takes a different tack. The MNA is pushing a bill to write “safe staffing” levels into law. It is one of several such initiatives in states across the country, and similar to a law recently passed in California. The union and its supporters claim that two-thirds of Massachusetts nurses who left patient bedsides for other opportunities would consider coming back if they could be assured of reasonable staffing levels.
In the latest version of the MNA proposal, nurses would care for no more than six patients at any point during their shift; in more acute nursing specialties, the ratio would be 1-to-3 or even less. The proposal also includes strong monitoring systems, including a toll-free hotline that patients or families could call to report inadequate staffing and fines for hospital violations, which would be posted publicly.
First proposing a similar measure in 1994, the MNA has long argued that unreasonable patient loads threaten quality of care, but the union’s case was bolstered by a 2002 study. Linda Aiken, a nursing professor at the University of Pennsylvania, found that the likelihood of a patient dying within 30 days of surgery increased by 7 percent when their nurses had more than four charges.
“When we first filed the bill, we knew staffing was at the root of the problem, but there was a lack of data,” says MNA executive director Julie Pinkham. “But now we have mountains of research. Inappropriate nurse staffing will either lead to increased length of stays or it will literally kill a patient.”
The MNA bill seems to be gaining momentum on Beacon Hill, where the union claims the support of more than 100 lawmakers. But critics charge that the”safe-staffing” push is as much about job security as patient security, with ratios remaining constant even for the night shift, when most patients are asleep.
Hospital administrators say they can use less-skilled LPNs (licensed practical nurses) to handle some tasks, and that the proposed legislation also does not take into account the mix of experienced and inexperienced nurses on a given shift. Moreover, they say that in California, mandated staffing ratios have left hospitals squeezed economically and paralyzed medically, forced to turn patients away from emergency rooms because they don’t have the staff required under the law.
“Obviously, we need more nurses and we need more time for those nurses to take care of patients,” says Dr. Donald Moorman, vice president for surgery at Beth Israel Deaconess. “But we can’t leave those patients unable to get care because of ambulance diversions.”
It’s one thing to mandate staffing levels; it’s another to come up with the staff to maintain them, says Sen. Moore, who scoffs at the claims of legislative support for the MNA bill. “People sponsor it because it’s like motherhood and apple pie,” he says. “Nurses are great, but making the thing work is a different story.”
Moore has his own bill, one designed to increase the supply of nurses in the Commonwealth. “You can’t create positions for people who aren’t there,” he says. “You need to prepare the field before you can reap the harvest.”
Moore’s plan calls for a $30 million trust fund to repay student loans for nursing-school graduates; it would also encourage mentoring programs within hospitals and fund recruitment drives. The staffing-ratio issue would be addressed by a “best practices” review of nurse staffing plans. Moore says it may also be possible to improve nursing care by shifting non-patient-care tasks to other hospital staff.
“Maybe there’s a better mix of people in terms of clerical support,” he says. “We need to look at how nurses are spending their time. It could mean a whole new way of training nurses [and] incorporating more technology, and it could mean we need to look at the whole job of patient care.”
The shortage of bodies is spreading to nursing school faculties.
But Moore’s recruitment-and-retention approach, which has the support of both the Massachusetts Hospital Association and the Massachusetts Organization of Nurse Executives, draws attention to another problem standing in the way of solving the nursing shortage: opportunities to gain nursing degrees.
According to the American Association of Colleges of Nursing, 583 students who qualified for admission were turned away from Massachusetts baccalaureate nursing programs last year due to lack of faculty or clinical facilities —and that’s counting the numbers from only 12 of the 15 programs in the state. Across the country, some 16,000 prospective nurses were rejected, primarily because of a lack of instructors and clinical space, according to the AACN.
In Massachusetts, the problem has been exacerbated by a wave of early retirements, encouraged as a solution to state budget woes, which caused a large number of nursing instructors to put up their feet prematurely. Applications to state nursing programs have gone up over the past two years, but because training capacity is shrinking rather than expanding, there hasn’t been a flood of new graduates: The Massachusetts Board of Registration for Nursing reports that 1,751 RNs graduated from nursing programs last year, a number that has steadily decreased from 2,371 in 1998. While admissions and enrollments have finally climbed back up to the levels they reached in 1998, experts maintain that their programs are at maximum capacity.
“We just don’t have enough faculty to take all of the people who would go into a nursing program,” says Shafner. “I just spoke up in New Hampshire, and they told me the situation was the same. There are waiting lists that are two, three, four years long at schools of nursing.”
Meanwhile, the state’s community colleges, which offer non-baccalaureate RN programs, are facing the same problem. In 2002, Northern Essex Community College lost seven of its 10 nursing faculty members to early retirement, though one instructor was brought back after four Merrimack Valley hospitals got together to assume the position’s $60,000 salary. Despite this attrition, NECC has expanded nursing enrollment in response to increased demand, but it will soon run into shortages in other health-related departments, according to Jackie Long-Goding, associate dean for health professions.
“If a nursing student can’t get anatomy and physiology, they can’t complete the program,” says Long-Goding. “I really don’t know how long we can do it. Clearly, the critical need will move from nursing to other areas that contribute to the education of a competent nurse.”
Moore’s bill calls for several nursing faculty initiatives, including allowing instructors who took early retirement to be re-hired without jeopardizing their benefits—an option reserved for critical professions. But at a time when hospitals and other health care providers are bidding up the salaries of nurses and nursing supervisors out of desperation, the difficulty of hiring and retaining nursing instructors extends to private nursing schools as well.
“Why do you think we have too few faculty?” asks Lea Johnson, assistant dean of the Northeastern University School of Nursing. “They can get paid $60,000 here, or they can work as nurse managers and make over $100,000 a year.”
Of course, that is the classic solution to a supply problem: bid up the price. Some say that could be the answer to the nursing shortage as well. One study, by Joanne Spetz of the Center for California Workforce Studies and Ruth Given of Deloitte Consulting, indicates that higher wages might draw young nurses into the profession as efficiently as they have brought some older nurses back into the fold.
New nurses won’t stay if conditions don’t improve.
But Pinkham, of the MNA, says keeping them there is another matter. “If you don’t fix the conditions, you’re not going to keep the people who go in,” says Pinkham. Recruitment efforts solutions “are a great thing,” she adds.”But if you recruit that college grad and get them into the system, and they still have eight patients when they should have four, they’re going to leave.”
For their part, hospitals have learned, through the current shortage, the price they pay when these key caregivers vote with their feet. Replacing experienced nurses costs as much as a year’s salary in recruitment, hiring bonuses, and fill-in time paid to an agency or per-diem nurse. For this very reason, however, some hospital officials worry that the financial enticements designed to draw in younger recruits—good pay, getting their educations paid for—might make nursing attractive for the wrong reasons.
“My concern is that as we have all these supply initiatives, we have to be sure we’re meeting people’s expectations as far as what the patients need them to do,” says Dr. Moorman. “There’s potential to have a situation where people have been drawn into the profession, and they’re still not ready to hold someone’s head while they’re vomiting.”Nursing may not be for everyone. But Barry Hayden, a former Franciscan brother who joined the profession 18 years ago, says hospitals had better figure out how to make their jobs more palatable before it’s too late. “Look around,” he says, gesturing to his colleagues outside of St. Elizabeth’s, almost all of them clearly many years out of nursing school. “Look at the people here. Ask yourself how old they are.”
Jeffrey Klineman is a freelance writer in Cambridge.