Changing how the world thinks about nursing

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July 6, 2010 -- Two recent press reports offer very different perspectives on the global nursing shortage, though they do have one thing in common:  the content of each piece is somewhat at odds with its own headline. On June 22, the Korea Times published Bae Ji-sook's "Shortage of nurses aggravating." From that headline, you might think that the piece would be about how the shortage means patients must sometimes put up with lukewarm tea. But in fact, the report powerfully describes the plight of under-staffed nurses asked to assume crushing workloads. The piece does not discuss potential solutions, and it might have made clear that under-staffing endangers patients. But it certainly shows how these conditions affect the nurses, portraying a workplace in which, according to the piece's main source, nurses "suffer from constant fatigue" and are "virtually isolated from the other part of the world because after work, all [they] can think about is getting enough sleep." And today, the Jerusalem Post ran a report by Judy Siegel-Itzkovich about the plans of the Israeli government to address that nation's shortages of health workers. The headline is "Panel decries nurse, doctor shortages," but even though about 75% of the profession-specific information here is about an alleged physician shortage, Israel appears to have a higher ratio of physicians to people than most countries, including the United States. The piece does mention a few government ideas intended to help nursing, including plans to introduce "nurse assistants" and to improve nurse recruiting and education, but there is no detail. In any case, we thank those responsible for these pieces, especially the Korea Times one, for drawing attention to a nursing shortage that has not gone away just because it has been discussed for more than a decade.

The other part of the world

A committee of experts

The other part of the world

To show how aggravating the nursing shortage really is, the Korea Times consults hospital nurse Song Eun-jeong, who has practiced for seven years and who is also head of the Korea Health and Medical Workers' Union's "policy department." Song urges the government and the public to address nurse under-staffing, though the piece discusses no specific solutions. Song herself seems thrilled to have just secured a position in a ward where her work day is guaranteed to last only from 9:00 am. to 6:00 pm., but from her account of current conditions, that sounds unusual:

We have day, evening and nighttime shifts and are obliged to work in rotation. We suffer from constant fatigue and a chronic lack of sleep. We are virtually isolated from the other part of the world because after work, all we can think about is getting enough sleep. ... It takes a certain period of time to train a nurse candidate to be a fulltime staff member. Therefore, the only way to make operations work with the limited number of workers is to make them put in more hours and sacrifice their private lives. No holidays, but late night shifts and other drawbacks. ... Marriage, pregnancy, childrearing and many other aspects compete for time in the hectic schedule. Though the management and the union agree to cap the number of night shifts to six days a month, the reality is that we work more than nine night shifts. 

And speaking of the effects of these working conditions on pregnancy, the piece adds a couple revealing details. In 2000, one Korean court reportedly ordered a university hospital to "compensate one of its nurses who suffered bleeding which led to a miscarriage." Another industry source adds that "female medical staff have to take turns to get pregnant so that their absence won't affect the whole operation of the ward."

Song notes that because nurses have so little time for each patient, "many family members or private guardians must take over the duty." The piece also notes carefully that "the union," presumably meaning Song, also "claimed that the shortage of medical staff lowers the overall quality of medical service." That sounds, again, like we might be talking about an imperfect restaurant experience, but in fact inadequate nurse staffing kills patients. In many nations, patients' families do take over when nurses are unavailable. But it's important to stress, as this piece does not, that lay persons cannot provide skilled nursing, and that they cannot monitor patients for subtle changes or administer complex treatments that can mean the difference between life and death. Family members are providing care, but not nursing care.

The piece does include some data and context confirming that these problems are widespread, though none of that tells readers how much under-staffing harms patient either. A recent survey by Song's union of more than 20,000 members reportedly found that "nearly 70 percent complained about the lack of staff," about 75 percent "said the work is imposing too much mental and physical stress on them," and "56 percent are considering getting another job other than at medical facilities." The piece also supplies a telling quote from the "online news outlet Medical Today," in which a "hospital manager" admits:

A nurse is responsible for over 20 patients. We know it is ridiculous but to run a hospital, it is unavoidable.

Is it? The report might have explored, at least briefly, why it seems to be unavoidable, and what if anything hospital executives and government officials plan to do about these conditions.

The report also says that shortages of "medical staff" are occurring in other nations, noting that the United States and Japan have been recruiting staff from overseas. The piece says this is because "the work requires extra attention dealing with life and death but at the same time require[s] long working hours"--seeming to attribute the shortages to the nature of the work itself. But there have not always been shortages on the scale we have seen in the last decade. And although health care has always been stressful, the current crisis is driven by things that could be addressed with adequate resources and restructuring care systems--and changing our attitudes about the value of certain work, such as nursing.

Still, on the whole the article is a valuable look at how the shortage and associated under-staffing affect nurses directly. In many nations, the shortage is less a product of an absolute lack of nurses than it is the result of nurses' unwillingness to endure the kind of working conditions this article describes. No profession can thrive when all its members can think about is getting more sleep. We must communicate that to "the other part of the world," and articles like this help.

A committee of experts

Today the Jerusalem Post published a piece entitled "Panel decries nurse, doctor shortages," by Judy Siegel-Itzkovich. The article says that a "committee of experts" submitted the 64-page report to Deputy Health Minister Ya-acov Litzman after "two years of study and deliberations" about how to "cope with the looming shortage of doctors and nurses." Among the recommendations are

establishing a new profession of nurse assistants; attracting Israelis studying medicine abroad and Western doctors to make aliya; attempting to close three international medical schools and finding more places for clinical teaching in hospitals.

The article does not say who served on the committee, apart from noting that its "chairman"  was Health Ministry chief economist Dr. Tuvia Horev. Telling readers how many physicians and nurses served on the committee might help them assess its recommendations. In any case, according to the Post article, Litzman is optimistic that the Ministry will be able to implement at least some of the recommendations.

The great majority of the Post piece focuses on Israel's alleged physician shortage. Health Ministry Director-General Dr. Ronni Gamzu reportedly says that there "only 3.4 physicians per 100,000 Israelis--about the same as the OECD average--but in those other countries the birth rate is generally much lower." However, the OECD says that in 2008, the OECD overall average was 3.2 physicians for every 1,000 people but that Israel had 3.6--far exceeding the OECD average, and incidentally, far higher than the U.S. ratio of 3.0 physicians per 1,000 people. Even if we assume that the current Israeli ratio is 3.4 physicians per 1,000, that is a relatively high ratio. Gamzu says the Israeli population is aging, some physicians are leaving the profession or the nation, and many in the growing number of female physicians want to work only part time. The piece goes into detail about which physician specialties are currently lacking sufficient numbers and which will in the near future (listing a total of 10). The report also describes the state of the nation's medical schools, explaining that a fifth medical school will open next year, but that even the 520 graduates a year that will allow is short of the 900 per year Gamzu says will be needed in 2022. A "major bottleneck" is the lack of clinical teaching facilities, Gamzu notes, especially since three universities with "international students" who "learn in English" are taking up clinical teaching facilities, and these programs should be closed. The ministry also plans to offer incentives to persuade Israelis who went to study medicine in Europe to return to Israel.

A brief discussion of nursing appears at the end of the article. Here it is in full:

There are only 5.5 nurses per 1,000 residents, which is already too low. The ministry has decided to launch a new profession--nurse assistants--who will be specially trained to carry out basic functions that nurses do but do not need to go to nursing schools to learn, such as helping a patient out of bed, operating some medical devices and others. Litzman noted that this profession could be attractive to haredi women, most of whom do not have matriculation certificates. In addition, the number of nursing education programs in colleges will be increased. More academics in other fields will be encouraged to retrain as nurses. However, the ministry has not yet decided whether to recognize the professions of nurse practitioners and physicians' assistants.

The nursing shortage has generally received a fair amount of attention from the media (policy-makers are another matter), but it receives relatively little attention in this article, even though it would seem that Israel's nursing shortage is much more serious than any physician shortage--the OECD says that in 2008, its members averaged 9 nurses per 1,000 people, compared to only 5.5 for Israel. Of course, there is some helpful information here, including the data about the low number of nurses. The nurse assistant point is also important, though nothing here tells readers just how complex an issue that is. Deciding what nurses can delegate to others and what they should do themselves can be controversial, especially when nurses themselves do not have adequate input on the decision. In the United States, hospitals have transferred a great deal of nursing work to unlicensed, relatively low-skilled workers in the last couple decades.

This saves money in the short term, but research shows that patient outcomes improve when more care is delivered by registered nurses instead of less qualified persons. Nursing assistants and other support workers can play important roles in health care, but they should not be used as a substitute for skilled professional nursing care, such as taking vital signs which may appear easy if all it seems to be is pushing a button on a machine. But those machines are not tested on the very sick, they malfunction and sometimes detect only half of all heartbeats, or sometimes, as in our experience, give healthy blood pressure readings on dead people (not kidding). Registered nurses can detect other signs and symptoms to help them determine when these machines malfunction that assistants cannot. And even tasks that may seem simple--like helping a patient out of bed--provide important opportunities for nurses to evaluate, educate and advocate for patients.

The piece's cursory treatment of nursing means other issues are not adequately addressed either. The report could have used more detail about the plans to establish new nursing programs and to encourage "academics" from other fields to pursue nursing--will the "academics" be training to become nursing professors, or does this just mean people pursuing other academic degrees? The article might also have included a little more discussion of the nurse practitioner and physicians' assistant issues. In some nations, nurse practitioners play a critical role in efforts to improve access to high quality care, especially for underserved populations. The piece might have noted whether any nursing specialties are particularly short of workers, as it does for the physicians. And the report might have consulted an actual nurse about these issues.

Obviously the Korea Times article is far more focused on nursing, but both pieces remind readers that the global nursing shortage continues to threaten nurses and take the lives of their patients. 

See the article "Panel decries nurse, doctor shortages" by Judy Siegel-Itzkovich, posted on July 6, 2010, on The Jerusalem Post website. You can reach the author at the Jersulem Post at

See the article "Shortage of nurses aggravating" posted June 22, 2010 on The Korea Times website.