Nurses

HEALTH REFORM: U.S. Nursing Shortage ... and My Mom

Veronica Valdez — Tue, 09 Jun 2009 13:24:00 -0400

I've been reading lately about the persistent nursing shortage in the U.S. that threatens the quality of patient care. I know something about this: I was born in the Philippines—the world's leading donor of nurse labor—and many of my own relatives, including my mother, migrated to the U.S. to help fill this nursing gap. My mother studied at the University of Philippines and was trained at the Philippine General Hospital. She, like thousands of others, was exported to the U.S. and then later to Australia in the '80s where she was guaranteed a higher salary and greater opportunities. This hasn't changed much. The mass exodus of nurses from the Philippines continues today.

But with the current economic crisis, is there still a growing demand for nurses in the U.S.? Some hospitals have laid off nurses. And some senior nurses are remaining in, or rejoining, the workforce as they choose to postpone retirement or come out of retirement because of financial insecurity.

But the American Association of Colleges of Nursing (AACN) assures us that the "U.S. is in the midst of a shortage of registered nurses (RNs) that is expected to intensify as baby boomers age and the need for health care grows." An analysis by the U.S. Department of Health and Human Services projects that the current nursing shortage will continue to grow in severity during the next 20 years if current trends prevail and that some states face a more severe shortage than do others." This is a sobering thought.

The shortage is not because people do not want to be nurses. Demand for nursing careers is high. Last year, AACN reported that almost 50,000 qualified applicants to nursing programs were declined. The underlying problem is the lack of nursing school faculty. The Obama Administration is paying close attention.

President Obama said during his White House Forum on Health Reform that:

Nurses provide extraordinary care. I mean, they are—they are the front lines of the health care system. And they don't get paid very well. Their working conditions aren't as good as they should be. And when it comes to nurse faculty, they get paid even worse than active nurses. So what happens is, is that it is very difficult for a nurse practitioner to go into teaching, because they're losing money.

HealthLeaders Media reports that:

President Barack Obama has requested $125 million for the federal Nursing Education Loan Repayment Program (NELRP). In addition, the president has asked lawmakers to increase federal Nurse Faculty Loan Program (NFLP) resources by 40 percent over 2008 funding levels as part of the $1 billion allocated for health care workforce development in the fiscal year 2010 budget.

Some states are also taking action. In Texas last year, nursing schools turned away some 8,000 qualified applicants, primarily because there weren't enough faculty to teach them. The Texas Legislature recently committed $30 million in new upfront funding for nursing schools to expand starting this fall. The Robert Wood Johnson Foundation and the New Jersey Chamber of Commerce Foundation have announced a $22 million five-year initiative designed to ensure that New Jersey will have the nursing workforce it needs to meet its future health care demands.

Addressing the nursing shortage (as well as larger issues about our primary care work force) is important in the grand scheme of health reform. As we try to get all Americans high quality affordable health care coverage, we will need more nurses to provide high quality health care and take on many of the challenges of care coordination, patient education, disease management and preventive care.

QUALITY: Temporary Relief in Nursing Shortage Won't Fix Bigger Problems

Meredith Hughes — Mon, 06 Apr 2009 17:47:00 -0400

We've all heard of the national nursing shortage, so why are newer nurses currently finding it so hard to get a job?

The answer lies in the economic recession and a temporary increase in the number of experienced, working nurses. As people feel the financial strain brought on by the current economic downturn, more of them, including nurses, are returning to work.

"We've got college costs in three years and our retirement plans are losing money," Tammy Frankauski, a mother of three who returned to work, told the Washington Post. "It's easier to keep ahead than risk falling behind, and you want to be prepared in case anything happens."

The nursing shortage has been a big problem for the past decade, and it's forecasted to get a lot worse in the next 20 years or so. In the past, hospitals have gone out of their way to recruit nurses and incentivize them to stay-offering signing bonuses, vacations, and on a positive note, quality initiatives.

However, hospitals are now actually turning away nurse applicants and reporting fewer job openings.

Problem solved? Not exactly. The return to work is a temporary financial incentive, so an economic upswing may well cause nurses whose return was only temporary to once again vacate their posts. And that scenario is not going to come at a good time—the aging baby boomer population is expected to significantly increase the need for health care resources in the near future. As the Institute of Medicine's report Retooling for an Aging America: Building the Health Care Workforce reminds us, 78-million baby boomers are going to start reaching age 65 in 2011. Baby boom nurses-the largest segment of the population-are going to retire. On top of that, a shortage of nursing instructors means that recruiting new nurses is going to be a difficult task. According to the Post, the American Academy of Colleges of Nursing reported that nursing schools turned away 27,771 qualified applicants last year because they didn't have enough instructors.

The nursing shortage hasn't been fixed, it's been temporarily hidden. We've got to be ready when the bubble bursts, and the best way to do that is by making sure the nursing shortage is addressed as health reformers work on rebalancing our work force to have adequate incentives for primary care, care coordination—and the nurses needed to fulfill those goals.

QUALITY: On-the-Job Training Lowers Turnover Rate of Nurses

Health Policy — Tue, 17 Feb 2009 19:15:00 -0500

After decades of letting newly-licensed nurses sink-or-swim on the job, some hospitals are finally tossing their new nurses a life preserver. The goal is both better quality care—-and fewer newly-minted nurses who quit.

According to the Los Angeles Times, a recent national study found that one in five newly licensed nurses quit within their first year of work. This is not what we need given our nursing shortage. Peter Buerhaus, of the Vanderbilt University Medical Center, told the LA paper that we could have a shortage of 500,000 nurses by 2025, due to increasing rates of retirement and the demands of the aging baby-boom generation. This shortage too comes at a time when nurses may actually have a larger role to play in a reformed health where we place more emphasis on primary care, care coordination, and management of chronic diseases.

Many nurses point to stress, lack of supervision, and poor on-the-job training as their reasons for leaving the field. Unlike medical school graduates, nurses have no formal residency in which they can get comfortable with their jobs, practice their skills, and gradually take on more responsibility for patient care. Most nurses are simply left to figure everything out on their own, a practice which strains their ability to deliver patient care.

In 2004, Childrens Hospital in Los Angeles started a program to help train new nurses and combat the high turnover rates. The Versant RN Residency, which has now spread to more than 70 hospitals across the U.S., pairs up new nurses with more experienced nurses. At first, the new nurse will just observe as she completes a lengthy checklist of competence in vital skills, but by the end of the 18-week partnership, the new nurse will be doing hands-on patient care work while the more senior nurse supervises.

Even though programs such as Versant cost about $5,000 per resident, the cost of replacing a nurse, including recruiting, training, and covering for a short-handed staff, will usually cost about 10 times as much. The Versant program in particular has been successful for many hospitals; the Baptist Health South Florida in Miami reports that the nurse turnover rate has dropped from 22 to only 10 percent since the program was implemented a year and half ago.

We sometimes fail to appreciate the vital role nurses play, both in the direct care they provide for patients as well as their insights into how to improve care systems. For any new care model to be successful, the cooperation and support of nurses is necessary. They are playing a big role in programs to help ease patients from hospital to home. Nurses are very close to the day-to-day work of a hospital, giving them an excellent vantage point for spotting problems in care delivery and innovating solutions. So nurse retention is good economics, and good medicine.

QUALITY: Happy Nurses, Healthy Patients

Joanne Kenen — Mon, 15 Sep 2008 16:21:00 -0400

Nurses just want to have ... autonomy.

Facing a worsening nursing shortage, often accompanied by poor morale, some hospitals are trying retain nurses not with cars, cash, and Bahamian junkets but by making their jobs more satisfying. And that can also improve the quality of patient care.

With more than 100,000 open nursing jobs last year—and the numbers expected to surpass one million about 15 years from now when aging Baby Boomers will need more nursing care—the nursing shortage is a serious problem for hospitals. A story in Sunday's Washington Post said the practice of luring nurses with signing bonuses and incentives turned out to actually boost turnover, because nurses would change jobs to keep accumulating bonuses

Replacing a nurse can cost up to $100,000 because of temps, overtime, recruiting and training the new nurse. That doesn't include salary. So hospitals took another look at what they can do to keep their nurses. And the answer, at least in part, is giving nurses more control over patient care and opportunities to get more advanced training. Some are doing research into problems they observe, coming up with new care plans that improve quality.

That can be better for patients too. One of the nurses profiled in the Post story, Jennifer Dimmick, now spends more time helping heart surgery patients learn how to take care of themselves and avoid complications when they go home. The program addressed a problem, identified by the nurses themselves, with a high hospital readmission rate for heart patients. "Autonomy is a big thing," Dimmick told the paper. "It's important for me to know that what I do matters."

The American Nurses Association has a credentialing program for hospitals that promote quality nursing and become "magnets" for good nursing. And good nursing means better patient care. Linda Aiken, a nationally known researcher on nursing at the University of Pennsylvania said that the magnet hospitals have lower death rates and fewer complications, which also helps contain costs.

QUALITY: Nurses In Time and Motion

Joanne Kenen — Mon, 21 Jul 2008 19:40:00 -0400

Nurses on medical-surgical units in hospitals spend less than a third of their time providing direct patient care. But before you get all indignant and leap to the conclusion that they are spending 70 percent of their time chatting on cellphones, doing their nails, or watching American Idol, think again. Nurses work hard. Very hard. But, through no fault of their own, they are not always working at maximum efficiency actually taking care of patients.

"A picture emerges of the professional nurse who is constantly moving from patient room to patient room, nurse station to supply closet and back to patient room, spending a minority of time on patient care activities," according to the interesting time and motion study called "How Do Medical-Surgical Nurses Spend Their Time?" published recently in the Permanente Journal, brought to our attention by the Robert Wood Johnson Foundation.

Nurses walk one to five miles a day, on 10-hour or longer shifts—a bit less walking on night shifts. Staffing shortages, poorly designed workspaces, tons of paperwork, inefficient medication storage and administration systems, and health information technology shortfalls limit the time they spend with patients. About half their time is spent on "indirect" care, including charting, paperwork (often duplicative), coordinating care from the nurses stations, and walking around—and around and around—gathering supplies. All this despite mounting evidence that direct patient care leads to better outcomes, the authors report.

The study, at 36 different hospitals in 17 different health care systems, looked at three basic approaches to hospital floor plans to see the physical design had much to do with patient care time; whether this could be an architectural issue rather than a systems issue. The answer was mostly no. In fact, there was more variation from one nurse to another in the same unit than there was between different floor plans. Which doesn't mean that given we are in the midst of a hospital building and renovation boom, architects and planners can't learn something. But the study more broadly suggested that documentation, medication administration, and care coordination could all be made much more efficient through changes in technology and work processes, as well as rethinking how med-surg units are organized.