Favourite worst nightmare
January 19, 2007 -- Over the past three days, Boston National Public Radio affiliate WBUR aired an extensive documentary on the nursing shortage called "Nursing a Shortage: Inside Out." Correspondent Rachel Gotbaum's series ran in three nine-minute segments in the mornings. The WBUR web site includes summaries of each segment and two essays by practicing nurses. Overall the series is a very good look at the causes and effects of the shortage as well as possible solutions, with many audio quotes from nursing scholars and executives. The online material also includes an excellent essay by ICU nurse Karen Higgins about the nature and value of her work. The series does not fully address certain aspects of this complex area, such as the profession's gender issues, and at times it seems a little too ready to accept at face value hospital positions on measures like the magnet program. But on the whole, the series is a serious and balanced treatment of a public health crisis, and we commend those responsible.
The first part of the series, "The Longest Running Nursing Shortage in History," examines the dimensions and causes of the shortage, with a little on possible solutions. The shortage, generally considered to have started in 1998, is now the longest in U.S. history, as Vanderbilt nursing professor Peter Buerhaus notes. Much of this material is familiar, including how managed care cost-cutting in the early 1990's led to nurses being laid off and replaced by less skilled workers, the relevant demographic shifts in the patient and overall populations, and the expansion of care technology. The piece reports that there are now about 118,000 unfilled nurse vacancies in U.S. hospitals.
The segment stresses that with expanding career options for women, the U.S. lost "a generation" of potential nurses. But it doesn't seem to consider whether nursing is necessarily composed only of women, or whether a key factor in the shortage is the profession's ongoing difficulty in attracting men, despite the presence of Buerhaus as one of the main experts consulted. The failure even to mention nursing's general imbalance is a fairly important flaw.
This segment does a pretty good job of describing the effect on patients when there are not enough nurses. Journalist Suzanne Gordon points to the research showing an increase in complications and deaths when nurses are short-staffed. The piece also quotes a local nurse executive as saying that the world learned its lesson about seeing nurses as expendable in the 1990's. We're not sure what the basis for thinking everyone has learned that lesson is, but it can't hurt for the piece to emphasize that nurses are not expendable. We're also not sure that all hospital executives have learned that nursing is not expendable, even though most now lament the lack of nurses to fill their open positions--does the average hospital executive understand that excellent nursing care save lives and improves outcomes?
The piece also touches on nursing's troubled image, explaining that many nurses see a gap between that image and reality. It quotes University of Hartford nursing professor Mary Jane Williams as emphasizing, correctly, that nurses are still seen more as handmaidens than as providers of life-saving care. The segment also describes recent public relations campaigns to promote nursing, running an audio clip of the "Dare to Care" theme song from the massive Johnson & Johnson Campaign for Nursing's Future. Curiously, the piece does not mention J&J, though it does say Gordon finds that such ads actually do a disservice to the profession, and may exacerbate the shortage, because they reinforce the angel stereotype. We agree that J&J's pre-2007 television ads have tended to have this effect.
Toward the end, the segment starts to look forward. It suggests that not all recent developments are bad for nurses. It reports that some nurses have started to receive more financial rewards, noting that senior nurses at major teaching hospitals can now earn more than US $100,000 per year. Buerhaus claims that nurses have come back to the bedside, but he warns that the shortage persists and will worsen unless more is done.
The piece also quotes highly skilled Massachusetts General nurse MJ Pender, who was one subject of the excellent 2005 Boston Globe series on training ICU nurses. Pender suggests that nurses are now involved in technical care discussions with physicians in a way that only physicians were when she started nursing almost two decades before. Pender says nurses are now seen as part of the team at the "top level," implying that they were nowhere near that in the past.
For us, this goes too far in suggesting that nurses now enjoy full respect from physicians and others for their nursing skills, which is plainly not the case overall. Yet it's too negative about past nurses, suggesting that nurses working as recently as the late 1980's were not seriously involved in important technical care. We think many nurses today are too eager to disparage their predecessors, in an understandable effort to put distance between themselves and the regressive nursing image. Unfortunately, this is not unlike the efforts of many modern career women to distance themselves from nursing as a whole because they associate nursing with unskilled drudgery and the severe professional limits women faced decades ago. Such attitudes, reflected in items such as ABC's "Grey's Anatomy" and the recent film "Gracie," look like feminism to many women. (You've come a long way, baby--a long way from nursing.)
The second part of the series is "Will There Be A New Supply Of Nurses To Meet The Growing Need?"--a fine question. The segment focuses on why we're unable to train enough nurses and what some hospitals are doing about it. Professor Williams notes that one key demographic change is that people are living longer. As they do, they require more health care, yet the nursing population itself is aging.
One result, the piece explains, is the surge in nurses from abroad. The segment reports that there are now as many as 200,000 foreign-trained nurses in the U.S., mostly from the Philippines. It includes quotes from Jee Bora, of New Bedford's St. Luke's hospital, who explains that one reason Filipinas like her become nurses is so they can come to the U.S. ("nursing is your passport to America"). The piece notes that foreign nurses face immigration issues and often need further training to practice in the U.S. The piece also suggests that "hospitals worry about causing shortages in other countries." But we are not aware that hospitals have done much to question the practice of luring nurses from overseas. In fact, unions and public health groups have questioned the aggressive efforts of some hospitals in the U.S. and other nations to recruit nurses from developing nations. The piece might have added that the huge influx of foreign nurses also raises questions about the ability of recent immigrants, from different cultures, to advocate effectively for patients in the U.S. clinical environment.
The segment explains that some hospitals are making efforts to help train nurses themselves. By this the piece does not seem to mean running diploma programs, but using financial incentives to encourage existing employees to become nurses. The piece focuses on a 47-year-old nurse at Heywood Hospital in Gardner. Three years ago, we hear, this nurse was a high school graduate whose job was "refinishing floors" at the hospital. Now, after getting his "community college degree," he is a psychiatric nurse. We applaud such initiative, but we have to note that no one would suggest this was an adequate answer to a physician shortage. Instead, we would be discussing how to interest more undergraduates at Harvard and Yale. The fact that the reporter would offer this extended example with no further comment speaks volumes about how nursing is still regarded as a profession. And if the profession cannot interest highly qualified young career seekers, it will have a problem replacing the huge numbers of nurses who will soon retire.
Of course, nursing has now reportedly started to interest larger numbers of qualified young career seekers. The piece notes that nursing school applications have risen dramatically and there are long waiting lists. It includes the familiar point that 147,000 "qualified" applicants were turned away from nursing programs in 2005, though as always, there is no mention of the standard under which they were deemed "qualified." Would any piece about a shortage of other highly trained professionals speak generally about "qualified" applicants? Who is "qualified" is to some extent a function of supply and demand. But we rarely see a piece mention the highly qualified class of nursing students schools can now enroll, as if it doesn't really matter once applicants meet some basic standard of "qualified." We've heard that at least one nursing program chooses students by lottery once applicants have met some basic standard. We're sure that will catch on with elite medical schools any day now.
The segment rightly focuses on the shortage of faculty as a key factor in the training bottleneck, noting that nurses can earn far more money in clinical practice than as educators. It explains that some states have made efforts to increase nursing educator salaries, but that there has been no significant actions at the federal level, even though, as Buerhaus notes, it would require only "decimal dust" relative to the entire federal budget. We think it might take a bit more than that to create lasting change, but Buerhaus correctly warns that the interest in the nursing shortage that now exists will not necessarily last forever.
The piece commendably shows that funding for nursing education alone will not resolve the shortage. Judith Rothchild of Boston College supports more money for nursing education, but she also foreshadows the series' final segment by arguing that "supply side" solutions never solve problems like this when what matters is the quality of the nurse's work life. If that life is untenable, new nurses will be "burned up" as fast as they are produced.
The third and final segment focuses on just this problem--why nurses are leaving the profession. The segment is "What Are Hospitals Doing To Keep Nurses Working And Happy?" It reports that a preliminary New York University study showed that about 20% of new nursing graduates leave the hospital within the first year. And the segment provides powerful illustrations. It takes listeners to work with a nurse who now cleans up biohazard sites (unusually messy death scenes) for a living. This nurse quit nine months after graduating at the top of her class because she felt stressed and utterly lost. She had not learned many of the nursing skills she needed at school, and no one at her hospital had time to teach her. She feared she would kill someone. She mentions an acquaintance who also graduated at the top of her class but quit in a year; she now has a dog-walking business.
The piece reports that hospitals are now trying to address these concerns by moving beyond financial incentives. Promising measures include extended orientations, and rapid response teams to help nurses with problems. The segment also notes that a small number of hospitals have achieved "magnet" status for creating environments that support nursing. As an example, the piece turns to a veteran nurse who left her former hospital for Jordan Hospital in Plymouth, one of five magnet hospitals in Massachusetts. The piece says the hospital has provided increased support for nurses' professional development, and increased nurse staffing by 25% in the last five years. The piece does not explain that many nurses have become disillusioned with magnet status, arguing that many hospitals seem to use it mainly as a marketing tactic, and that many revert to prior practice once they have received the designation.
The piece reports that the most contentious issue in improving nursing practice environments is staffing. The chief nurse at Jordan, Carol Dilloplane, stresses that staffing is critical, and that a nurse with eight patients is not doing nursing so much as a "bunch of tasks." This is good but of course not the whole story; one key study found that a nurse with eight patients is also 31% more likely to see her patients die. Dilloplane also says that Jordan's increase in staffing has helped to reduce vacancy and turnover rates by more than 75%. Even so, Dilloplane is not an advocate of the mandatory nurse-patient ratios that unions like the Massachusetts Nurses Association (MNA) favor.
The piece reports that mandatory staffing ratio legislation is pending in more than a dozen states, including Massachusetts, but so far only California has enacted such a law. The piece does not say what effect the law has had in California. It does report that such a law would cost hospitals millions in increased labor costs. It does not mention a study Buerhaus himself co-authored suggesting that better nurse staffing would not greatly increase overall costs in some scenarios. The piece quotes a former hospital association representative as suggesting that ratios would create "cookie cutter" care. However, the piece notes, many local nurses are determined to force hospitals to ensure a minimum level of staffing. It quotes former MNA leader Karen Higgins as saying that the situation will only change if the staffing is taken out of hospitals' hands.
In closing, the third segment asks whether these measures will be enough to address the impending shortfall. It turns to Buerhaus, who suggests that the coming shortage may be worse than anything the U.S. has ever seen before. In fact, it sounds like it already is.
The documentary web site also includes two essays by practicing nurses. One is "Why I Stay: A Day in the Life of ICU Nurse Karen Higgins." The site does not note that Higgins is the former president of the MNA. Higgins does an excellent job of explaining what ICU nurses like her do for patients. She makes clear how autonomous nurses are, and how they save lives through their mastery of highly technical care. In particular, Higgins describes in detail how she saved a patient by detecting very subtle changes in his condition and persuading an attending cardiologist to repeat an echo cardiogram (why haven't we seen that on "House"?). As a result, this patient was rushed to surgery. Higgins rightly feels good about this, but we have to wonder who got the credit; who would the patient say saved his life? We understand New Jersey Gov. Jon Corzine thinks he survived his recent eight day stay in the ICU because of a great "team of doctors."
Higgins also gives an impassioned statement of why she believes nurses are important:
Like air traffic controllers, we watch over our patients making sure they remain safe and don't crash. We are the surveillance system for our patients. But as a nurse I not only monitor my patient's condition--but I am also [a] pilot who delivers complex technological care on a minute by minute basis. As the nurse I am the one person who is responsible for the patient's survival from the moment he or she comes into my care and making [sure] that care is continuously tailored to meet the patient's needs.
I love being a nurse and love using my years of experience and skill to care for patients and their families at perhaps the most difficult time of their lives. But the expectations of nurses have become unrealistic. I cannot be in two places at once--and as [the] patient's medical needs become more complex, I worry that I will not be there at a critical moment to access a patient in need. For the last twenty-eight years I have been my patient's last line of defense and will continue to be there until I can no longer provide safe care.
The warning implicit in the last sentence is ominous.
The other essay, "A Day in the Life of an Emergency Room Nurse," was written by Sarah Carlson, who seems to be fairly new to the work. She does a good job of conveying how complex and overwhelming work on a critically injured patient can be, as various members of the ED team try to save a trauma patient apparently injured in a motor vehicle accident. The piece also gives a fairly effective blow-by-blow account of various measures the team takes for the patient. Parts of this essay convey uncertainty and a mainly emotional focus. And the piece may leave some readers with the sense that the nurses' role is more to act as skilled assistants to physicians rather than pursue an autonomous practice model (a resident "takes charge"; later she "orders" Carlson to begin giving blood products because of the patient's low blood pressure).
We thank Ms. Gotbaum, WBUR, and NPR for this extensive and generally helpful series on the nursing shortage.
Please send messages of thanks to Rachel Gotbaum at firstname.lastname@example.org and please copy us at email@example.com. Thank you!