Part two of this feature looks at problems that contribute to the nurse shortage, the problems that result from it and suggestions on how to fix them. 

As the health care industry plays its semantic and statistical games with whether or not there’s enough "real" evidence to prove that patients suffer when there aren’t enough nurses and direct-care health professionals to tend them, patients are dying and a profession whose ranks are depleting continues to suffer.

There is by, now, however, enough real evidence that the nation is facing a severe shortage of nurses (see the January-February 2001 issue of Healthwire): the number of nursing school graduates is diminishing and the nurse workforce is graying. Equally real are the reasons for that shortage.

One of the top causes of the shortage we’re facing comes from the health care industry, which created its own problems a few years ago when it swirled into a frenzy of cost cutting in reaction to competition and insurance companies’ demands. Hospitals took the short-sighted approach of cutting their highest-paid nurses—who were, of course, the most experienced and most highly skilled—and hiring in their place "unlicensed assistive personnel" who would be directed by RNs acting as "team leaders." Schemes to restructure, reengineer and redesign hospitals and health care delivery (remember "patient-focused care" and "total patient care"?) may have given hospitals a better bottom line, but they also resulted in deskilling, displacing, deprofessionalizing and disempowering the nursing workforce.

A diminished nurse population plus a sicker patient population, and the overwhelming paperwork that comes with increased regulations and insurance company and managed care contract demands, have all combined to create nurse burnout.

"Now, more than ever, America can afford quality health care for everyone," says AFT president Sandra Feldman. "Instead, it’s more insecure than ever and more driven by boosting profits. And we know that health care professionals are bearing the brunt of the turn this industry has taken.

"The health care industry is being transformed by trends that put profits first and patients last," says Feldman, who adds that nurses are seeing what those trends mean.

These health industry trends have caused the diminishing ranks of health professionals, overwhelming patient loads and the imposition of mandatory overtime to deal with it all.

Health Professionals and Allied Employees/AFT member Barbara Rosen, testifying at a New Jersey state senate committee hearing last year said: "Hospitals literally drove nurses out of the profession through layoffs, attrition and horrific working conditions. Nurses left the profession from stress, exhaustion and the feeling that they were no longer providing quality care." The Star-Ledger, which covered those hearings, reported that the nurses testifying described today’s hospital and nursing home work environments as being "sweatshop conditions."

Those sweatshop conditions no longer are taking a toll ‘only’ on the health, lives, careers and psychological states of the providers—they are taking their toll on patients’ lives and the quality of care.
 

The silence is broken

In a groundbreaking series last year that took nearly a year of investigative research, Chicago Tribune reporter Michael Berens broke the silence that health professionals have been keeping on the patient care problems being caused by understaffing.

Berens’ investigative series, which ran in three parts last September, began with the statement: "Overwhelmed and inadequately trained nurses kill and injure thousands of patients every year as hospitals sacrifice safety for an improved bottom line…." Berens wrote that, since 1995, "at least 1,720 hospital patients have been accidentally killed and 9,584 others injured from the actions or inaction of registered nurses across the country, who have seen their daily routine radically altered by cuts in staff and other belt-tightening in U.S. hospitals."

"The numbers may be small," Berens told Healthwire, "but we could prove each and every one. It was the first time we were able to quantify what was happening to patients and the breakdown in nursing care."

This series, which was, fundamentally, about how staffing shortages are affecting patient safety, was a 10-month project, Berens explained, "looking not at what was being said but what was happening out in the workplace."

One of the first hurdles in the story project, said Berens, was getting an answer to the fundamental question: "Are there fewer nurses working in hospitals than five years ago?" He says that the official answer from the American Hospital Association was that there are actually more nurses than ever before, in fact there’s a record number. "Nurses are telling us privately that there are fewer [nurses] and there are more problems."

In going beyond the official answer, Berens said he found that the statistics from the AHA were misleading and even padded when presented to the public. The AHA nurse count was the total number of nurses working in all divisions, not just hospitals—in nursing homes, off-site, in home health care. What he wasn’t getting, said Berens, was the breakdown.

"When we started looking at direct nursing care, we saw that the majority of hospitals had substantially decreased the number of direct care nurses assigned to patients." And, said Berens, he traveled from coast to coast looking at hospitals to confirm that this was the case.

"For example, I looked at a Florida hospital that began at a one-to-one ratio then a one-to-two ratio for ICU patients. Then shortly before I arrived they made it one RN to three ICU patients and that was controversial.

"The way it was structured: the nurses would have a direct view into the rooms of two patients" but getting a third patient meant that one would be outside their direct view. "While I was there, the hospital changed it again and decided on a one-to-four ratio in ICU, which is abnormally high.

"That underscores what we were seeing in a lot of hospitals: continuing to add to RNs’ duties."

In Kansas, some nurses were carrying 25 patients per nurse on medical-surgical floors, said Berens. "One to 15 was normal in dozens of facilities. Many nurses will argue one to eight is much more normal."

In his Chicago Tribune series, Berens wrote about a woman named Shirley Keck who suffered irreversible brain damage during her stay at Columbia/HCA’s Wesley Hospital in Wichita, Kansas. When her breathing became labored and difficult, Keck’s daughter ran to the nurses’ station several times for help but found no one. The staffing that evening was three RNs for 41 critically ill patients. The Keck family sued the hospital administration for short staffing and the case was settled out of court for $2.7 million. According to the American Trial Lawyers Association, this is believed to be one of the first legal cases that targets corporate-level staffing decisions rather than individual negligence, wrote Berens.

"In the past, why haven’t the media done these stories?" Berens asks. "Because it’s tough to quantify the problem." His report broke through that barrier and quantified the problem, attaching specific numbers to specific problems. And health care professionals everywhere, instead of attacking Berens, were grateful that the public was finally let in on the problems that have been driving them out of the profession.

"Historically, nurses have been silent about the problems they see every day," said Berens. "The cultural [norm] is not to speak out, and to be professional and work within the system."

What he says he’s seeing now is an empowering of nurses around the country. The radical stance of some health professionals’ groups is "wonderful," he emphasizes, and "a lot of their strategies are fantastic."

The Federation of Nurses and Health Professionals publicly declared the Tribune report a "clarion call for nurses to organize, mobilize and unionize to fight back to save our patients and save our profession."

The tragedies "detailed in the investigative series and the hundreds more that happen every day will continue until nurses across the country… take control of their profession," wrote FNHP leader and AFT vice president Candice Owley in a letter to the Chicago Tribune editor. Owley said nurses should have the power to decide appropriate staffing levels, to leave when they have had to work too many hours to ensure patient safety, and to refuse to perform tasks for which they haven’t been adequately trained. Nurses should also have whistleblower protection so they can expose quality problems without fear of retribution, she noted.

The most savvy groups, says Berens, are not just going to the public on their own to say there are problems, they are partnering with the public, "so it’s not just the nurses saying they’re being overworked."
 

So what’s to be done?

"Where will the next generation of caregivers come from when the extraordinary women who built this profession—who are this profession—and young people are looking at other options?" asks Feldman. "Nursing is a full-fledged profession and, like teaching, it has ironically benefited from discrimination [in other areas of employment]. Now, we need not just women, but men, too, to see this as a fulfilling career."

"We need to explore more fully the solutions," adds Feldman, who emphasizes that recruitment strategies must consider both men and minorities as candidates for nursing professions.

Peter Buerhaus, RN, PhD, who is associate dean for research at Vanderbilt University School of Nursing, agrees that one of the actions that can be taken to increase the supply of RNs is to eliminate the stigmas and barriers facing men and minorities.

In a four-part series on the nurse shortage published in Nursing Economics journal, Buerhaus and colleagues outlined additional actions for increasing the nurse supply: improving the image of nursing, reducing the costs of nursing education, developing ways to keep older RNs in the workforce, and allowing more foreign-educated RNs in the United States, as well as eliminating the stigmas and barriers.

The AFT, along with a number of other union and nursing groups, insists that unsatisfactory working conditions must be remedied before we can expect to see an increase in the number of licensed professionals working in hospitals. Issues like workload, staffing, career opportunities and competitive pay all must be addressed—which is just what unions like the AFT are doing.

Federation of Nurses and Health Professionals/AFT locals throughout the country have already bargained into their contracts controls on mandatory overtime, better pay, more involvement in decision-making and other measures that will keep and attract health professionals. AFT health care locals are doing exactly what Berens suggests—they are partnering with the public to get out the word on unsafe conditions and to devise strategies to restore and protect high-quality health care.

Contrary to the claims by understaffed hospitals that they can’t find nurses to fill jobs (though nurses say those jobs often aren’t posted, despite what hospitals say), Berens told Healthwire he found that hospitals offering better pay and working conditions have no trouble at all in hiring the nurses they need.

FNHP members and other health care professionals throughout the country have also been the catalysts for the passage and introduction of national and state legislation that sets minimum staffing ratios, prohibits mandatory overtime, mandates the use of safer needle devices, and protects workers on the job who are trying to protect patients from unsafe practices.

State and national legislators are currently getting in on the act; hearings on the nursing shortage have been held this year already in Minnesota , New Jersey, and Connecticut and at the federal level. The U. S. Senate Committee on Health, Education, Labor and Pensions’ Subcommittee on Aging held a hearing on the nursing shortage and its impact on America’s health care delivery system on Feb. 13 with a number of witnesses testifying. Sen. Barbara Milulski (D-Md.) told participants that the way to "get behind" our nurses is to pay them what they deserve.
 

Measures being taken

Just as a matter of survival, communities and hospitals are already taking measures of their own to attract and retain nurses.

Hospitals are offering to cover the cost of two-year nursing programs and are starting their own in-house training programs for specialty areas. Other employers are offering nurse signing bonuses, child care and even maid or lawn service.

The American Association of Colleges of Nursing found that there are some already proven strategies that can boost enrollments in nursing schools, including encouraging associate-degree nursing graduates to continue their education; recruiting from bachelor’s- to master’s-degree programs with financial incentives; advertising and promotion to recruit new "talent"; priming the "pipeline" through programs that work with high school and younger students. "Many schools have stepped up efforts to provide tutoring and remedial opportunities for English as a Second Language, set up mentoring programs targeting minority high schoolers, and link up with historically black colleges," reports the AACN.

The AACN and other nursing groups point out that improving financial aid to nursing school candidates and polishing the image of nursing both must be done as well.

"The epidemic of disillusionment among health care professionals is as serious as an epidemic of disease among patients," says Feldman, "and it requires national attention before it is too late."

Read part I of "Supply and Demand" in the January-February 2001 issue of Healthwire.