Nursing in Crisis: How Hospitals are Dealing With the Shortage

The Current State of Nursing

Healthcare delivery has undergone critical change over the last several years, and the nursing profession has changed along with it. The end result: A reduction in the supply of qualified, experienced nurses. Those who remain are working under conditions of heavier case loads, technological complexity and increased acuity of patients. A condition which once warranted a lengthy in-patient stay is now treated on an out-patient basis, largely because of managed care requirements.

According to Debbie Pickup, Director of Human Resources at Southcoast Healthcare System and a former R.N., "The nurse's role of patient care is the same, but the importance has escalated. Since hospital stays are shorter, a patient who undergoes surgery used to stay for one week, but now only stays two to three days. Nurses must assist the patient to bring him or her to a functioning level and put together a plan to support the patient and assure quality care, while discharging sooner." According to Barbara Munro, Dean of Nursing at Boston College, "Nurses have said that the problem has been the working conditions - too few nurses, not enough support, an uncertain future, and forced overtime."

The role of patient families has also changed in the last decade. "Both patients and their families are more educated and involved in the process," according to David DeJesus, Vice President of Human Resources at Southcoast Healthcare System. "Families used to trust the care of the patient to physicians and nurses; now it's common that family members stay 24 hours a day, ask questions about the care, and put more demands on the nurses."

Reasons for the Shortage

The current shortage in qualified, experienced nurses is not expected to improve over the next several years. In fact, the majority of senior level nurses and nurse managers are reaching retirement age. As they exit the profession, fewer nurses will be available or willing to assume a management role. The current climate of understaffing, 24-hour shifts, increased management responsibility, and increased acuity of patients often leaves younger nurses reluctant to fill the gap.

Dean Munro sees the problem continuing. "Most nurses are around 45 years old, white, suburban women, 80% of whom are currently working full-time. As they retire, they often leave because they're burnt out; unfortunately, there are simply not enough nurses to replace them."

Only a few years ago, industry analysts were stating that there was an over supply of nurses - not so anymore. Why aren't there enough nurses to replace those who are retiring or leaving the profession? Hiring managers are finding that younger Baby Boomers and Generation Xers are no longer viewing nursing as a viable profession because of the difficult work environment combined with a desire for more control, quality and balance in their lives. In addition, women have more choices of fields to enter. As one 20-year nursing veteran put it, "There are simply more options open to bright women interested in healthcare; before there was only nursing - now there is 'medicine'. I recently took my daughter to work one day, but frankly, I'm not encouraging her to become a nurse. The working conditions are horrendous, the responsibility is huge, patients are acute, and the workload index is high."

According to Dean Munro, the national level of enrollment for nursing is down, although applicants to Boston College have risen. Of 20,000 applicants, only the upper echelon (about 2,000) is accepted. Boston College, Yale, and other academic institutions are forming "accelerated programs" to attract those who wish to change careers. Accelerated programs enroll people who already hold bachelor's degrees in other fields into a one-year intensive nursing program or a two-year master's program. The average age range for program applicants is 25 to 35 years old.

Debbie Pickup from Southcoast Healthcare System witnessed an increase in the average age of incoming nurses. "The age of new nurses used to be around 21 or 22; now graduates have varied ages, often in the mid-30's. For many of them, nursing is a second career. They enter into a more acute clinical environment, where patients are sicker and more complex. Although schools have changed the curriculum, entry level grads have only basic skills - there is a great gap in the readiness of the individual."

How Hospitals Attract and Retain Nurses

Hospitals must now compete with one another to attract and retain nurses in a very competitive market. Southcoast's DeJesus notes that some hospitals are using preceptor programs to ease the transition of new graduates into high-paced, technologically complex clinical settings. "Since new grads need more clinical experience, many hospitals create a professional development transition program. In addition to a week-long orientation, this program combines classroom time, and practical time with an experienced staff member for six months. This mentor relationship helps with a gradual introduction. Preceptors are trained and compensated. Mentors are often volunteers. It is a supportive transition that has received a very positive response."

Hospitals have had to be flexible in their approach to overcome the shortage. Use of travel nurses, for example, fills gaps whenever needed. Many nurses, particularly older nurses, often work "per diem" to keep working without the pressure of a full-time commitment. During a shortage in the early 80's, some Boston-area hospitals even recruited nurses from other countries, such as Ireland. Other approaches include sign-on bonuses worth several thousands of dollars, referral bonuses, and flexible hours. Flexibility of hours may allow nurses to work three 16-hour days, for example, with the next four days off. For women with children, a flexible schedule can be very important.

Southcoast's Debbie Pickup adds, "Most hospitals are now focusing on retention. It is becoming critical to pay attention to all factors that are important to RNs in the clinical setting: having a voice and the ability to have some control over the practice of nursing. For example, a unit council meeting takes place on a regular basis and identifies issues and concerns to patient care. Years ago the nurse manager addressed this issue. Now TQM requires that more people are included in the problem solving and decision-making. Staff members are more involved in operational issues. Although some individuals still prefer that management fix all the problems, for the most part it works quite well."

Pickup added, "The professional relationship between the nurses and physicians plays a factor on retention of nurses. If there is a good relationship, one that is consultative, respectful, and supportive, then job satisfaction is increased. If, on the other hand, the relationship is not positive, there is a higher turnover in the nursing staff."

Dean Munro strongly suggests that hospitals work closely with the nurses to determine their needs and establish their value to the organization. "Perhaps the best ICU ever created was when nurses worked with the architects to design the unit. They designed a better unit simply by talking with the nurses."

Her advice to hospital management: "Work with the nurses to see what is needed to improve job satisfaction. The number one concern is not always salary - it has to do with improving working conditions, being recognized for what they do, and obtaining the opportunity to learn new things. Nurses need to get a sense that they have done a good job for their patients. Listen to the nurses. Empower them. Make them part of the process. That process will be improved and so will the quality of patient care."

This article is drawn from Phillips DiPisa’s Thought Leadership Library. You can find more perspectives on managing today’s complex healthcare organizations on our Web site at www.PhillipsDiPisa.com.

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