Nurses
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Nursing Shortage
Puts Patients at Risk
Inadequate Staffing
Sparks Rise in Medical Errors
An In-Depth Look at the Nursing
Shortage ... and Why It May Get Worse
A shortage of
trained and experienced nurses has become a serious problem for most hospitals
and long-term care institutions, and a critical problem for some. The present
nurse shortage, however, is only an early warning sign of a public health
catastrophe that looms ahead, starting eight to 10 years from now.
Unless a number
of current trends can be reversed, by 2010 -- if not sooner -- there will
be so few nurses able and willing to provide bedside care that hospitals
and nursing homes may be compelled to cut back their services. And the
situation will keep getting worse, until hospitals may be forced to turn
away all but the most critically ill patients.
This Shortage
Is Different
Nurses are
the backbone of the healthcare system. In hospitals, doctors diagnose,
prescribe and perform surgery. Nurses provide the treatment they order.
Physicians check on their patients daily or more often, but the lives of
critically ill and post-surgery patients depend on the 24-hour-a-day presence
of nurses, and on their skill, experience and vigilance.
There have been
nurse shortages before, but this one is different. Earlier ones were cyclical
in nature, from the perspective of a veteran nurse-executive, Stella Shiber,
Ph.D., the associate dean for professional education programs and practices
at Johns Hopkins Hospital's School of Nursing in Baltimore, Md.
When nursing
or teaching were the main professions in which women were welcome, she
says, few young women went to nursing schools with the intention of making
nursing a life-long career. Many left their jobs fairly soon to marry and
raise families, or they got married and worked only part-time.
Regional shortages
have occurred from time to time for various reasons, often the difference
in pay between smaller city and rural hospitals and large urban ones. New
graduates always came along to correct any maldistribution of the nursing
work force, or older nurses returned to work.
Today's shortage
cannot be cured that way, because the number of graduates from schools
of nursing is down sharply. That is one of the reasons for today's rapidly
growing scarcity of nurses, but is itself an effect of deeper underlying
causes.
Fewer Women
Choose Nursing Careers
One of the
root causes of the short supply of nurses is that virtually every occupation
is now open to women, and in the last 30 years or so a robust economy has
created many new jobs for the highly trained. In the 1960s and 1970s a
large number of high school graduates entered nursing schools. That changed
drastically in the 1980s.
A new study
of the nursing crisis made for the American Organization of Nurse Executives
sums it up: "A diminishing number of women in the under 30-year-old population
cohort are entering nursing because today's women have more career choices
available to them that are less stressful and more accommodating to a balance
between family and career demands." And many of those jobs, Shiber notes,
are also more prestigious and high paying in fields such as business, computer
technology and engineering.
Nurses are not
only becoming fewer, but grayer. Their average age is increasing faster
than that of any other occupation. In hospitals, the average age of registered
nurses (RNs) increased by 5.3 years between 1983 and 1988. During this
same period, the number of working RNs under 30 fell from 419,000 to 246,000,
a decline of 41 percent.
By 2010 the
average registered nurse will be over 45, and about 40 percent will be
over 50. About the same time, the first of the 78 million baby boomers
will retire and become eligible for Medicare, greatly increasing the demand
for medical services. Thousands of nurses will be among those retirees,
causing a shortage that the AONE report calls "unprecedented in magnitude."
Budget-Cutting
Hits Nurses Hard
A second major
cause of the present nurse shortage is that, beginning in the late 1980s,
hospitals, nursing homes and other long-term care facilities were caught
in a financial squeeze play between inflation on the one hand, and cutbacks
in their income caused by the rise of managed care on the other. Health
management organizations (HMOs) and insurance companies, each in their
own way, began to dictate what they would pay for and how much.
As HMOs and
health insurers imposed more and more limitations on what they covered
and the fees they would approve, hospitals' incomes shrank, and they had
to cut their expenses to keep from operating at a loss. An axiom for budget-cutters
is to look at the biggest ticket items first, and a hospital's largest
single payroll item is nurses' salaries. Hospitals, including some of the
largest and most prestigious, began to lay off some of their best-paid
nurses -- who were also among the most experienced and highly trained.
It was a shortsighted
response, Shiber says, and her opinion is one that is widely held. Veteran
nurses were replaced with less experienced ones, and with technology, technicians
and nursing assistants. The nurses who remained had to shoulder greater
patient loads, and some began to complain publicly that patient care was
being degraded.
One of the earliest
and most prominent critics of those policies was Laura Gasparis Vonfrolio,
R.N., Ph.D., a consultant on critical care and medical-surgical nursing,
who edited the 1990 book "Nurse Abuse," which she and 10 other nurses wrote.
"The diminishing number of staff nurses at the bedside compromises the
attention and care that every patient has a right to expect," she wrote
in the book's preface.
Vonfrolio and
her co-authors detailed what they meant by nurse abuse: Nurses who were
already working 12-hour shifts were being compelled also to work overtime;
their pay, which had always lagged behind that of other occupations requiring
comparable education and dedication, was becoming ever more inadequate
in the face of inflation; they were not being consulted in decisions affecting
their profession; and their central role in healthcare was too little understood
and valued, even by physicians and hospital administrators.
But those things,
they wrote, were not the primary reason ever-growing numbers of nurses
were leaving hospital staff work. A mushrooming patients-per-nurse ratio
caused by budget-cutting, and the ever-increasing burden of paperwork required
by HMOs, insurers and Medicare, were making them unable to give the quality
of care they were trained to provide and which their patients needed. And
they found that intolerable.
Politics
Played a Role, Too
Until 1997
payments from Medicare, to some extent, protected hospitals' incomes against
further decreases. The Balanced Budget Act (BBA) of 1997 removed that safety
net.
Both President
Clinton and a Republican-controlled Congress were determined to end the
federal government's deficit spending and begin paying off the national
debt, while also cutting taxes. In negotiations before the BBA was passed,
they agreed on a $250 billion reduction in federal spending between 1998
and 2002, with nearly half -- $119 billion -- to come from a slowdown in
the growth of Medicare spending. About two-thirds of that amount would
come out of payments to hospitals.
Some of the
BBA's authors were surprised and most of the medical community dismayed
when, partly because of an aggressive effort to stamp out fraud and waste
in the program, the growth of Medicare spending turned out to be lower
than the original projection, by more than $91 billion.
Hospitals that
had already drastically cut their operating costs were faced with new major
reductions in their income. Particularly hard-hit were hospitals that serve
a disproportionately large number of patients who are poor, very ill and
frequently uninsured; rural hospitals that depend on public subsidies to
stay open; and teaching hospitals, where new doctors are trained.
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