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The State of the Profession: "Code White: Nurse Needed"

March 1, 2005 -- Today The State newspaper, of Columbia, South Carolina, ran the final installment of a massive, three-part special report by Linda H. Lamb about the nursing shortage, "Code White: Nurse Needed." The report addresses the causes of and potential solutions to the shortage, and it has many excellent elements, notably extensive examinations of the problems with nursing's public image, issues related to men in nursing, and aspects of the training of new nurses. Perhaps the most glaring problem is the report's failure to mention what many believe is the primary immediate cause of the current shortage, namely the managed care-driven hospital budget cuts of the 1990's which led to the dangerous nurse short-staffing that has driven many nurses from the bedside. The piece gives the impression that any short-staffing is merely an effect of the shortage, rather than a leading cause of it. In addition, a short sidebar on the growing use of foreign nurses in the U.S. fails to mention the devastating effect such migration is having on the health systems of many developing nations.

The special report consists of three long articles published February 27-March 1. Each of the three is accompanied by relevant sidebars, "nurse vignettes," which are three short quotes from nurses or nursing students that echo the basic themes of the article, and a collection of photos. The first article, "Aging population drives crisis," explains how "South Carolina is coping with the nursing shortage--and why it will get worse." The piece explains some of the basic parameters of the problem, including the aging population, the aging nursing workforce, and the devastating nursing faculty shortage, which has led to the rejection or waitlisting of many qualified nursing school candidates. The piece deserves credit for citing recent research linking higher nurse staffing and better educated nurses with better patient outcomes, and for explaining the magnet hospital concept. The piece is also commendably nurse-driven, using nurse sources almost exclusively, though one section features quotes from a local ED physician about the need for more experienced nurses on "his staff": "I don't have the experience [on the staff] that I want to have." Perhaps this person actually is the administrative manager of the ED, but if a nurse held that position (as many do), we wonder if a piece would feature a quote from him or her about whether she had adequate physician experience on staff. This physician is also identified as "Dr. Ron Fuerst," but no quoted nurse receives the doctoral label, even though at least three have doctorates: South Carolina Board of Nursing head Sylvia Whiting, Medical University of South Carolina (MUSC) nursing dean Gail Stuart, and leading Vanderbilt nursing shortage expert Peter Buerhaus, on whom the piece seems to rely more heavily than any other single source. Consistent with this failure to fully appreciate the autonomous and intellectual components of nursing, the lengthy piece never really explains what it is that nurses do to save lives and improve patient outcomes.

On the whole this part of the report suggests that the shortage is not a crisis now, but may become one in a few years when the baby boomers retire, citing statistics that show an increase in the number of nurses in the last few years and lower hospital vacancy rates. Of course, vacancy rates are a function of positions the hospitals decide are necessary, and may or may not reflect real patient needs. To its credit, the piece cites Buerhaus for the idea that the current shortage is different from prior ones because of its deep demographic bases and its duration: four times longer than any previous shortage with no apparent end in sight. But the piece fails to identify hospital staffing and other budget cuts driven by the increasing influence of managed care and declining reimbursement rates in the 1990's as a primary cause of the shortage, suggesting that a lack of nurses is a threat to patient safety, but never that nurse short-staffing is the result of anything but a simple lack of nurses. There is no mention of the fierce ongoing battles over mandatory nurse staffing ratios in California and Massachusetts, nor of the many local hospital labor disputes that have centered on nurses' objections to short-staffing. Many nurses feel the nursing shortage is a crisis right now, here and around the world, and that it has claimed countless lives. This is not an obscure point; it has figured heavily in a number of national articles and books on the shortage in the last few years. Even if the piece countered the assertions of nursing activists with multiple hospital administrators arguing that hospital and insurer decisionmaking is no factor in the shortage, the failure to even raise the issue is a grievous one. The piece does include quotes from nursing leaders decrying the lack of sufficient action by the South Carolina legislature to address the shortage, and it notes that surrounding states seem to be doing more, for instance creating nursing centers to coordinate efforts to improve working conditions and recruiting.

The first part of the report concludes with what seem to be brief previews of the later two parts. The first of these sections introduces the problem of the low rates of men and minorities in nursing, citing the many other career options for those in these groups (and for "bright female students"), and the difficulty of overcoming prevailing stereotypes. The piece notes that a local hospital's human resources director "hates" Ben Stiller's "warped and bumbling male nurse" character in the 2000 film "Meet the Parents." In fact, that is not a fair description of the smart, caring and resourceful Stiller character, who overcomes just the kind of stereotypes the piece is discussing, but it illustrates the understandable sensitivity to such stereotypes in the current social environment. The final section notes that time, energy and money is being spent to address the shortage, but it's not clear yet what is working; it closes with Buerhaus arguing that the single most important thing states can do now is to address the critical faculty shortage.

Perhaps the most noteworthy and commendable aspect of the special report is that the second part, "Image problems are a subtle, persistent factor," focuses on the role of nursing's public image in the shortage. It's fairly unusual for pieces on the shortage to spend much time on this, even though in our view the deep and widespread public undervaluation of nursing is the bedrock problem underlying most of the more immediate causes, including short-staffing and the demographic factors. Lamb effectively frames the image discussion with a scene from the popular NBC drama "ER" in which resident physician Greg Pratt rejects a care idea from nurse Abby Lockhart, saying, "I fly the plane. You serve the coffee." The piece accurately summarizes the message as being that the physician is the male "sovereign" and that the nurse is the female "handmaiden," including a quote from MUSC dean Gail Stuart that "that attitude is quite pervasive." The second part of the report ends with a note that hospitals should hope nurses do not respond to such attitudes as Lockhart did, since "[t]ired of Pratt's condescending bluster, Lockhart went on to medical school," and "[n]ow, she's a doctor." In fact, the episode with Pratt's "coffee" comment aired in April 2002 and the episode in which Lockhart decided to return to medical school aired in October 2003; there was no such direct causation. But Lockhart's decision did appear to be driven at least in part by feelings of disrespect from physicians and the public. Of course, nurses are about 100 times more likely to pursue graduate education in nursing than medicine, or (sadly) to simply leave the bedside. "ER"'s presentation of the "coffee" comment was intended to show that Pratt was arrogant and green--the show was not consciously endorsing the comment--but much of "ER" actually does support the myth that physicians provide all significant care, and the episode, very typically, contained no effective rebuttal of the substance of Pratt's remarks. It is surprising and unfortunate that the second part of the report, despite using "ER" as its central example, does not really examine the impact of the media itself in fostering and reinforcing the social attitudes it discusses.

However, the second part does provide a great deal of valuable material. It describes some of the efforts hospitals have made to curb "I fly the plane" physician arrogance, including emphasizing teamwork, monitoring physician conduct, and supporting nurses' advanced training. Yet the piece rightly notes that the persistent "image of feminine subservience" continues to deter today's male and female students. The piece profiles veteran male nurses who have battled through the stereotypes, notably that they must be gay. It deserves credit for including a candid comment by one that he spent a lot of time "overcompensating" by doing "manly, adventure-type things," and for noting that some male nurses feel that female nurses actually resent them. The piece explains why the male nurses it profiles have stuck with nursing, but does not sugarcoat the difficulties. One complains that, while there are plenty of female physicians on "ER," male nurses are rare. (In fairness, the percentage of female physicians in real life is much higher than that of male nurses, though more male nurses do work in the ED.) The piece then circles back to the importance of good relationships with physicians, and the difficulties caused by physician disruptive behavior, which remains a problem. A local OB/GYN describes physician mentoring programs his hospital has implemented to curb such behavior, and a medical school dean stresses that fostering a team approach in his students enhances their critical ability to collaborate with nurses. His message: "A good nurse can save you hundreds of times a day." What he means is, a good nurse can save patients hundreds of times a day, but we'll take it. Finally, the piece addresses the nursing uniform issue, noting that the proliferation of colorful scrubs has made nurses harder to identify, and that some feel the newer uniforms seem less professional. Here again, we learn that "Dr. Ron Fuerst" "has had to draw the line at male nurses in do-rags." The second part closes by suggesting that "what may do the most to improve nurses' image is their own commitment to professionalism," citing hospitals where nurses play a major role in generating patient safety ideas and are encouraged to obtain advanced certifications. It might have also noted the importance of nurses--and the media--speaking up about just what nurses do to improve patient outcomes; there is little in this piece to tell people exactly what that is.

The third part of the special report, "Hospitals, educators getting creative," examines efforts to resolve the shortage. It focuses on hospital "efforts to create a culture where nurses feel valued," which includes "creativity, collaboration and cash," as employers focus on "competitive pay and perks, flexible schedules, reducing paperwork, enhancing patient safety, and buying special lifting equipment to spare nurses’ backs." The piece also discusses hospital mentoring, educational innovations, the merits of shift bidding in reducing vacancy rates and the use of agency nurses, and outreach to potential new nurses like middle school boys. It discusses the benefits of "nurturing" hospital nurses through mentoring, the use of patient simulators to streamline clinical education, and the efforts of South Carolina hospitals to attain magnet status, which is designed to reward hospitals that "empower and respect nurses;" apparently none of the hospitals have magnet status yet. Commendably, the piece explains magnet status in some detail, noting that it is associated with lower death rates, shorter stays, and better outcomes generally. Although the piece fails to discuss in any depth the growing ranks of master's-prepared advanced practice nurses--a potential career path that may attract many to nursing--it does note that it's a great time to be a nursing student, as potential employers lavish students with attention, perks and offers. But here again, the failure to examine the short-staffing issue is glaring. Some would contend that when these bright-eyed students hit the continuing reality of short-staffing, there is a significant risk that, perks or no perks, they will not be at the bedside long--assuming they even realize the extent to which they are unable to provide the critical care their patients need, since they may never have had the chance to see such care given. The piece discusses potential legislative assistance for nursing education, including quotes from a state legislator who co-owns an assisted living facility and believes that ultimately "the market will solve the problem" through rising salaries. The piece could have benefited from a response to this view, particularly from someone involved in efforts to ensure adequate staffing. Despite this, the third part of the special report concludes with an excellent quote from local health economist Lynn Bailey, who stresses that the shortage is a patient-safety issue: “Patients, fundamentally, go to the hospital for nursing care...When you give highly qualified, experienced nurses too many patients to take care of, mistakes happen, and patients die.”

A short sidebar, "Hospitals turn to foreign-born nurses," accompanies the third part of the report. Also written by Ms. Lamb, this item notes that although foreign nurses are not yet a huge factor in South Carolina, local hospitals have recruited a number of Filipino nurses. The piece focuses on two such nurses. These two note that despite some bigotry and other obstacles, they have assimilated and are satisfied with their work, as well as the far higher salaries that drew them in the first place. A local nursing director notes that the Filipino nurses have done well on the national licensing exam. The piece does not explore the potential difficulties some have identified in care from some foreign-born nurses due to differences in training and social factors that may not be measured on exams, such as the ability and inclination to perform U.S. nurses' vital patient advocacy duties. More broadly, the piece fails to mention that the migration of nurses to wealthy nations with shortages has dealt severe blows to a number of developing nations with health systems that are already fragile, including the Philippines. Nor does it discuss the ethical implications of active recruiting of such nurses, which has become a significant issue internationally, though it is rarely mentioned in U.S. articles.

The photos accompanying the pieces show many of the nurses and places discussed in the report. They provide a pretty good portrait of nursing diversity and of the training of new nurses by senior ones. However, one photo shows an NP-in-training in an OR setting where, as the caption describes it, "anesthesiologist Dr. Thomas Warren...walks over to instruct the nurse anesthnatist [sic]," who is not shown. Obviously, we don't know what was really going on here, but it's pretty clear that most readers will get the idea that anesthesiologists tell nurse anesthetists what to do in OR settings. In fact, certified nurse anesthetists are highly autonomous professionals whose care has been shown to be at least as good as that of anesthesiologists, though in most states they must nominally work under the "supervision" of anesthesiologists. If the paper was going to mention the nurse anesthetist at all, it should at least have given him or her a name, rather than leaving the reader with Dr. Warren instructing some nameless nurse. Spelling "anesthetist" correctly would have been a bonus.

On the whole, although there are significant flaws in The State's special report, the paper and Ms. Lamb deserve a great deal of credit for making an unusually serious and comprehensive effort to address the crisis in nursing.

See the three-part series "Code White: Nurse Needed" by Linda H. Lamb: Part I "Aging population drives crisis" on February 27, 2005; Part II "Hospitals, educators getting creative" on February 28, 2005; and Part III "Hospitals turn to foreign-born nurses" in the March 1, 2005 edition of the The State. Also see the Nurse Vignettes.

You can reach Linda Lamb at (803) 771-8454 or