- Email: [email protected]
The nursing shortage: What can we do?
Clinical Notebook The nursing shortage: What can we do? Author: Polly Gerber Zimmermann, RN, MS, MBA, CEN, Chicago, Ill
A
n international registered nurse (RN) shortage, worse than any previous one, is predicted. The reasons are complex and include both societal and professional factors. They are1-4: 1. An aging nursing workforce. The average age of nurses is 42 to 46 years; baby boomers (those born between 1946 and 1964) will start to retire in or before the year 2011. California predicts that 50% of their nurses will no longer be practicing by the year 2012.5 2. Declining nursing school enrollment for new nurses, with older nursing students. The average age of the new graduate nurse is 31 years old. 3. Increasing opportunities within and outside of nursing because of a robust economy. Nursing is hard, demanding work in an environment of many lucrative opportunities. 4. Growing demand. The Bureau of Labor Statistics predicts that the RN job market will grow 23% by the year 2006.1 By the year 2020, the prediction is that the need for RNs will rise 36%.6 5. Changing post-baby-boomer demographics. A smaller pool of future workers is coupled with increased volume and acuity in health care. The population of those 82 years of age and older is growing at a rate that is 6 times faster than the rest of the population.7 The US Census Bureau estimates that by 2020, the number of people 85 years or older will have doubled.6 6. Increasing preference of “greying” nurses to work part time. This trend results in vacant staff RN hours, even with the same number of working
Polly Gerber Zimmermann, Illinois ENA, is Instructor, Department of Nursing, Harry S Truman College, and Associate Nurse, American Airlines, Chicago O’Hare International Airport, Chicago, Ill. For reprints, write: Polly Gerber Zimmermann, RN, MS, MBA, CEN, 4200 North Francisco, Chicago, IL 60618; E-mail: pzimmermann@ ccc.edu. J Emerg Nurs 2000;26:579-82. Copyright © 2000 by the Emergency Nurses Association. 0099-1767/2000 $12.00 + 0 18/9/111528 doi:10.1067/men.2000.111528
nurses. Nationwide, one study found a 20% deficit in available staff RN hours.8 7. Resulting ramifications of health care re-engineering. Job redesign often excessively burdened the RN. In fact, in 1996, American Hospital Association (AHA) President Dick Davidson warned national hospital executives about the “thinning” of nursing staff.9 In addition, some hospitals began demanding unlimited mandatory overtime to cover their current nursing shortage, resulting in the exit of many experienced, but overwhelmed, nurses from the profession.
The Bureau of Labor Statistics predicts that the RN job market will grow 23% by the year 2006. By the year 2020, the prediction is that the need for RNs will rise 36%. The solution To find a solution to this problem, processes beyond stop-gap measures need to be considered. Suggested approaches include traditional, short-term, and longterm proposals. Traditional approaches One traditional answer focuses on attractive financial options, such as referral fees or higher compensation, to recruit a nurse.8,10 However, a sign-on bonus loses its luster without gaining loyalty once the nurse is on staff. Hiring just anyone, even when a manager knows the applicant is the wrong person for the job, creates a lose/lose situation that only compounds the problem. Enticing current employees to work more hours is another approach.8,10 Premium pay is offered to existing
December 2000 579
JOURNAL OF EMERGENCY NURSING/Zimmermann
staff. They voluntarily increase their hours for a period of time, often over a known seasonal shortage such as summer vacations or Christmas holidays. However, the Lawrenz Consulting annual staff surveys indicate a high incidence of nurse burnout when a facility’s overtime hours reach more than 13% to 15%.11 Circadian experts recommend that persons limit their overtime hours to 300 to 350 per year.12 Short-term approaches Restructure orientation and mentoring, especially for the new graduate. Many hospitals are beginning to realize that effective preceptorships are vital, especially for new nurse graduates. Although the overall national RN turnover rates are around 14%, one survey found that 20% of new RN graduates leave during their first year of hospital employment. Anecdotally, it is as high as 50%.8 Instead of scaling back on training, as the AHA indicates many hospitals have done,6 Johns Hopkins’ Senior Director Amy Deutschendorf, MS, RN, AOCN, suggests expansion of training. She plans to provide extra assistance throughout the first year of practice. Her orientation program includes mandatory competencies, gradual hierarchical introduction of responsibilities, and adjusting the patient loads for the orientee/preceptor pair.8 Invest/reward staff longevity.8 A 1999 survey by Lawrenz Consulting11 found that in the hospitals that responded, the average budget for education was 3.5%, compared with most successful industries, which invest 5%. Deutschendorf also advocates use of additional training resources, pointing out that re-engineering resulted in the loss of the clinical specialist in many hospitals. That role was pivotal in assisting nurses with on-the-job learning in today’s rapidly changing health care environment. One compensating solution is that many hospitals offer didactic classes, paired with a personalized “internship,” to develop their specialty nurses. Adjust the hospital work environment to make it more appealing. Changes with managed care and federal Medicaid and Medicare reimbursements have affected hospitals’ revenue. The AHA estimates that 1500 hospitals are operating in the red.6 However, nursing services were cut even in financially thriving hospitals to preserve historic profit levels.9 Whereas hospitals regularly blame an RN shortage for staffing deficiencies, in reality, the problem is more often a shortage of nurses willing to work with the current conditions in today’s hospitals.9 Nurses want a decent and safe atmosphere and staffing levels in which to practice.
580 Volume 26, Number 6
The legitimacy of their concerns is coming to the forefront. Of the top 11 JCAHO sentinel events, 5 have a proven relationship to staffing and 3 have an anecdotal relationship to staffing.8 Investigative reporter Berens blames working conditions that place excessive pressure on RNs, rather than incompetent individuals, for nursing errors. He found that since 1995, at least 1720 patients have been accidentally killed and 9584 patients have been accidentally injured by RNs.9 As a result of working conditions, many nurses have chosen to leave bedside care. It is predicted they will return when the environment is fixed. Use more accurate measures of accounting for the nurse workload for appropriate staffing. Historically, the midnight census and ED total patient census determined staffing numbers. Yet patients are not equal. In addition to acuity concerns, increased nursing time is involved in the activity of patient admissions, discharges, transfers, and holds of today’s shortened length of stay. For emergency departments, one promising improvement is a more precise triage scale with interrater reliability and test/retest accuracy. The refined Emergency Severity Index (ESI), developed by Richard Wuerz, MD, and colleagues at the Brigham and Women’s Hospital in Boston, has a statistically significant correlation to the patient’s vital status. Already it has validated the high acuity of the Brigham’s ED population and is being used in consideration of adjusting staffing levels.13-15 Reexamine the concept of partnering with higher level assistants. Unlicensed assistive personnel (UAP) remain a concern. Under the care of nurse aides, 564 US hospital patients have been injured since 1995.9 California enacted mandatory patient staffing ratio legislation, sponsored by the California Nurses Association, in 1999. The law included strict UAP job description guidelines that eliminate procedures normally done by nurses. These procedures include venipuncture, tube feedings, invasive procedures (including insertion of nasogastric tubes, catheters, or tracheal suctioning), and/or postdischarge care.16 Consultant Marie Manthey, RN, MSN, states that the most effective use of an auxiliary partner is when that role can do 75% of what the RN can do. Then a group of responsibilities can be delegated, rather than an isolated task. She advocates the increased use of licensed practical nurses, partnered consistently with the same RN.8 However, many ED managers report underutilization when persons in higher trained assistive roles, such as a respiratory therapist, replace RNs.17
Zimmermann/JOURNAL OF EMERGENCY NURSING
Consider mandated staffing ratios. A controversial suggested solution is that of the California legislation, which requires a minimum, specific, licensed nurseto-patient ratio for all acute care hospital units.16 More than 20 other states are considering similar legislature. Some oppose this approach because they fear that minimum staffing levels will become the ceiling. This situation could possibly lead to required staffing numbers that are unsafe at times. An involved trauma case may require a number of RNs. Other factors, such as skill mix and staff competency, are also considerations. Recruit from other countries. Nearly 1 in 10 Canadian nursing graduates from 1995-1997 migrated to the United States.18 Recruiting hospitals report that these nurses are well-trained, have excellent skills, and easily adjust to the differences in our health care system.8 Long-term approaches Reconsider how nurses are being used. Consultant Holly A. DeGroot advocates examining to what extent nurses are spending their time nursing. For example, one ICU had a staffing ratio of 1:2, but the RNs spent less time on direct patient care than did RNs on other units because they lacked supportive systems, such as unit clerks and equipment delivery. Documentation is another time-consuming task. Nurses in one emergency department spent the equivalent of 6.8 full-time employees per day (eg, 54 hours) on charting.8,19,20 From a different angle, consultant Cavouras suggests including unit clerks and assistive personnel in the hospital’s float pool. Otherwise, the temptation to “just send a nurse” occurs when the staffing need could often be met adequately by someone with less training.8 Accommodate the older worker.4,7 Keeping older nurses working in the hospital, even part time, provides staff and experience. Human Resource Director John Vicik advises changing job descriptions, benefits, schedules, training, and recruitment to accomplish this goal. He suggests the following: 1. Create a descending clinical ladder, allowing nurses to fill positions with less responsibility for less compensation, similar to what is done in Japan. 2. Offer benefits that older workers typically value, such as vision care or shorter shifts, rather than child care. 3. Accommodate normal aging changes, such as having training materials in larger print on nonglossy paper.
4. Recruit in senior citizen centers and churches instead of the classified ads, which most older workers do not read. Cavouras reports that a lift team has been a tremendous source of satisfaction at one rural hospital. A team of young employees and a mechanical lift, instead of “greying” nurses, provide this physical service for heavier patients.8
One ICU had a staffing ratio of 1:2, but the RNs spent less time on direct patient care than did RNs on other units because they lacked supportive systems, such as unit clerks and equipment delivery. Reexamine registered nurses’ wages. Nursing wages have basically remained flat in the environment of a growing economy.9 Nursing experience and education are not appropriately rewarded. Just as teachers have clamored for fair compensation for their work, nurses need to insist their vital work be adequately rewarded financially. Begin active recruitment among untapped adult candidates. The profession often overlooks traditional but promising sources of future nurses. Many current, non-nursing hospital employees chose to work in a health care environment because they enjoy helping others. Having a local college’s nursing program recruit right at the hospital is an effective technique. Many recent immigrants see nursing as offering a higher entry-level income than most other associate degree–level opportunities. English as a Second Language classes or ethnic cultural centers are prospective places to begin to foster an awareness of the opportunities available in nursing. Improve nursing’s image. When nurses are not able to give adequate care, it is important to convey that. One floor’s staff even wrote in large letters across the patient identification board, “We are not able to give good care today because we are short staffed.” Even in trying times, most nurses can recall meaningful moments of touching another person’s life. Few professions offer such immeasurable
December 2000 581
JOURNAL OF EMERGENCY NURSING/Zimmermann
rewards. Nurses need to emphasize these rewards when talking with the public. Also, continued vigilance for accurate media portrayals, such as a recent mobilization against one company’s ad that portrayed a nurse as scatter-brained, is important. Instill the nursing vision in young children. Positive contacts with children can be initiated with activities ranging from teddy bear clinics to school visits. Many of today’s nurses recall the impact of an impressionable story or encounter on their own lives.
A call to nursing’s roots A range of opinions about what can be done to address this pending nursing shortage exists. The answers are still evolving. However, no expert suggests replacing the trained, educated, socialized RN with a piecemeal distribution of tasks to lesser qualified UAPs. Repeated studies show that such actions have a negative impact on quality patient care. Decreases in RN staffing coincide with a rise in hospital errors, infection rates, and readmissions. The higher ratio of RNs to non-RNs, specifically the RN hours of care per patient per day, has been proved to improve patient care outcomes.21-24 Editor Leah Curtin sounds the summarizing theme by calling nurses back to their roots. Nursing is a profession which, by definition, focuses on helping and giving. The emphasis of nursing is not business, which is a focus on production and profits. In the end, stressing nursing ideals will help restore the magnetic pull to its life-changing work.25 References 1. Curtin L. A crisis in the making: key facts. CurtinCalls 1999;1:15. 2. Silvestri GT. Occupational employment projections to 2006. 1997, November. Monthly labor review. Washington, DC: Bureau of Labor Statistics. 3. Sloane M. Survey says…more nurses needed. Nurs Spectr 1999;12:16. 4. Zimmermann PG. Healthcare institutions get out of the box and on the edge with the nursing shortage. Nurs Spectr 2000;13:28-9. 5. Jacobs C. Kaiser’s workforce initiative. CurtinCalls 1999;1:7-10. 6. Berens M. Training often takes a back seat. Chicago Tribune 2000 Sept 11;Sect. 1:1, 6, 7. 7. Vicik J. Recruitment/retention. In: Zimmermann PG. Manager’s forum. J Emerg Nurs 2000;26:367. 8. Zimmermann PG. Manager’s forum. J Emerg Nurs. In press.
582 Volume 26, Number 6
9. Berens MJ. Nursing mistakes kill, injure thousands. Chicago Tribune 2000 Sept 10;Sect. 1:1, 20, 21. 10. Labarre L, Jones S. Recruitment/retention. In: Zimmermann PG. Manager’s forum. J Emerg Nurs 2000;26:363-7. 11. Lawrenz Consulting Group. 2000 Staffing survey results. Perspect Staffing Scheduling 2000;19:1-6. [The Perspectives on Staffing and Scheduling is a bimonthly publication of Lawrenz Consulting, 9012 N Cobre Drive, Phoenix, AZ 85038; phone (602)788-0027.] 12. Coburn E, Sinois W. A lifestyle how-to for night-shift nurses. Nurs Manage 2000;31;28-9. 13. Wuerz RC, Milne LW, Eitel DR, Travers D, Gilboy N. Reliability and validity of a new five-level triage instrument. Acad Emerg Med 2000;7:236-42. 14. Wuerz R, Travers D, Gilboy N, Yazhari R, Eitel D. Implementation of five-level triage at two university hospitals. Poster at Society for Academic Emergency Medicine Annual Meeting, San Francisco, CA, May 2000. 15. Travers DA, Waller AW, Bowling JM, Flowers DF. Comparison of 3-level and 5-level triage acuity systems [abstract]. Acad Emerg Med 2000;7:233. 16. Farella C. California staffing law gains national attention. Nurs Spectr 2000;13:11. 17. Griswold A. In: Zimmermann PG. Manager’s forum. J Emerg Nurs 1997;23:641-2. 18. Pond C. Northern exposure. NurseWeek 2000;13:1, 31. 19. DeGroot HA. Patient classification systems and staffing, part 1: problems and promise. J Nurs Adm 1994;24:43-51. 20. DeGroot HA. Patient classification system and staffing, part 2: practice and process. J Nurs Adm 1994;24:17-23. 21. Blegen MA, Goode CJ, Reed L. Nursing staffing and patient outcomes. Nurs Res 1999;47:43-50. 22. Kovner C, Gergen PJ. Nursing staffing levels and adverse events following surgery in US hospitals. Image J Nurs Sch 1998;30:315-21. 23. Bond CA, Raehl CL, Pitterie ME, Franke T. Healthcare professional staffing, hospital characteristics, and hospital mortality rates. Pharmacotherapy 1999;19:130-8. 24. Moore K, Lynn MR, McMillen BJ, Evans S. Implementation of the ANA report card. J Nurs Adm 1999;29:48-54. 25. Curtin L. Mandated ratios in a downsized market [keynote address]. Presented at A Staffing Crisis: Nurse/Patient Ratios [sponsored by CurtinCalls and Cross Country University]; 2000 July 21-3; Washington, DC.
Send descriptions of procedures in emergency care and/or quick-reference charts suitable for placing in reference file or notebook to Gail Pisarcik Lenehan, RN, EdD, c/o Managing Editor; PO Box 489, Downers Grove, IL 60515; phone (630) 6631263; E-mail: [email protected].
A
n international registered nurse (RN) shortage, worse than any previous one, is predicted. The reasons are complex and include both societal and professional factors. They are1-4: 1. An aging nursing workforce. The average age of nurses is 42 to 46 years; baby boomers (those born between 1946 and 1964) will start to retire in or before the year 2011. California predicts that 50% of their nurses will no longer be practicing by the year 2012.5 2. Declining nursing school enrollment for new nurses, with older nursing students. The average age of the new graduate nurse is 31 years old. 3. Increasing opportunities within and outside of nursing because of a robust economy. Nursing is hard, demanding work in an environment of many lucrative opportunities. 4. Growing demand. The Bureau of Labor Statistics predicts that the RN job market will grow 23% by the year 2006.1 By the year 2020, the prediction is that the need for RNs will rise 36%.6 5. Changing post-baby-boomer demographics. A smaller pool of future workers is coupled with increased volume and acuity in health care. The population of those 82 years of age and older is growing at a rate that is 6 times faster than the rest of the population.7 The US Census Bureau estimates that by 2020, the number of people 85 years or older will have doubled.6 6. Increasing preference of “greying” nurses to work part time. This trend results in vacant staff RN hours, even with the same number of working
Polly Gerber Zimmermann, Illinois ENA, is Instructor, Department of Nursing, Harry S Truman College, and Associate Nurse, American Airlines, Chicago O’Hare International Airport, Chicago, Ill. For reprints, write: Polly Gerber Zimmermann, RN, MS, MBA, CEN, 4200 North Francisco, Chicago, IL 60618; E-mail: pzimmermann@ ccc.edu. J Emerg Nurs 2000;26:579-82. Copyright © 2000 by the Emergency Nurses Association. 0099-1767/2000 $12.00 + 0 18/9/111528 doi:10.1067/men.2000.111528
nurses. Nationwide, one study found a 20% deficit in available staff RN hours.8 7. Resulting ramifications of health care re-engineering. Job redesign often excessively burdened the RN. In fact, in 1996, American Hospital Association (AHA) President Dick Davidson warned national hospital executives about the “thinning” of nursing staff.9 In addition, some hospitals began demanding unlimited mandatory overtime to cover their current nursing shortage, resulting in the exit of many experienced, but overwhelmed, nurses from the profession.
The Bureau of Labor Statistics predicts that the RN job market will grow 23% by the year 2006. By the year 2020, the prediction is that the need for RNs will rise 36%. The solution To find a solution to this problem, processes beyond stop-gap measures need to be considered. Suggested approaches include traditional, short-term, and longterm proposals. Traditional approaches One traditional answer focuses on attractive financial options, such as referral fees or higher compensation, to recruit a nurse.8,10 However, a sign-on bonus loses its luster without gaining loyalty once the nurse is on staff. Hiring just anyone, even when a manager knows the applicant is the wrong person for the job, creates a lose/lose situation that only compounds the problem. Enticing current employees to work more hours is another approach.8,10 Premium pay is offered to existing
December 2000 579
JOURNAL OF EMERGENCY NURSING/Zimmermann
staff. They voluntarily increase their hours for a period of time, often over a known seasonal shortage such as summer vacations or Christmas holidays. However, the Lawrenz Consulting annual staff surveys indicate a high incidence of nurse burnout when a facility’s overtime hours reach more than 13% to 15%.11 Circadian experts recommend that persons limit their overtime hours to 300 to 350 per year.12 Short-term approaches Restructure orientation and mentoring, especially for the new graduate. Many hospitals are beginning to realize that effective preceptorships are vital, especially for new nurse graduates. Although the overall national RN turnover rates are around 14%, one survey found that 20% of new RN graduates leave during their first year of hospital employment. Anecdotally, it is as high as 50%.8 Instead of scaling back on training, as the AHA indicates many hospitals have done,6 Johns Hopkins’ Senior Director Amy Deutschendorf, MS, RN, AOCN, suggests expansion of training. She plans to provide extra assistance throughout the first year of practice. Her orientation program includes mandatory competencies, gradual hierarchical introduction of responsibilities, and adjusting the patient loads for the orientee/preceptor pair.8 Invest/reward staff longevity.8 A 1999 survey by Lawrenz Consulting11 found that in the hospitals that responded, the average budget for education was 3.5%, compared with most successful industries, which invest 5%. Deutschendorf also advocates use of additional training resources, pointing out that re-engineering resulted in the loss of the clinical specialist in many hospitals. That role was pivotal in assisting nurses with on-the-job learning in today’s rapidly changing health care environment. One compensating solution is that many hospitals offer didactic classes, paired with a personalized “internship,” to develop their specialty nurses. Adjust the hospital work environment to make it more appealing. Changes with managed care and federal Medicaid and Medicare reimbursements have affected hospitals’ revenue. The AHA estimates that 1500 hospitals are operating in the red.6 However, nursing services were cut even in financially thriving hospitals to preserve historic profit levels.9 Whereas hospitals regularly blame an RN shortage for staffing deficiencies, in reality, the problem is more often a shortage of nurses willing to work with the current conditions in today’s hospitals.9 Nurses want a decent and safe atmosphere and staffing levels in which to practice.
580 Volume 26, Number 6
The legitimacy of their concerns is coming to the forefront. Of the top 11 JCAHO sentinel events, 5 have a proven relationship to staffing and 3 have an anecdotal relationship to staffing.8 Investigative reporter Berens blames working conditions that place excessive pressure on RNs, rather than incompetent individuals, for nursing errors. He found that since 1995, at least 1720 patients have been accidentally killed and 9584 patients have been accidentally injured by RNs.9 As a result of working conditions, many nurses have chosen to leave bedside care. It is predicted they will return when the environment is fixed. Use more accurate measures of accounting for the nurse workload for appropriate staffing. Historically, the midnight census and ED total patient census determined staffing numbers. Yet patients are not equal. In addition to acuity concerns, increased nursing time is involved in the activity of patient admissions, discharges, transfers, and holds of today’s shortened length of stay. For emergency departments, one promising improvement is a more precise triage scale with interrater reliability and test/retest accuracy. The refined Emergency Severity Index (ESI), developed by Richard Wuerz, MD, and colleagues at the Brigham and Women’s Hospital in Boston, has a statistically significant correlation to the patient’s vital status. Already it has validated the high acuity of the Brigham’s ED population and is being used in consideration of adjusting staffing levels.13-15 Reexamine the concept of partnering with higher level assistants. Unlicensed assistive personnel (UAP) remain a concern. Under the care of nurse aides, 564 US hospital patients have been injured since 1995.9 California enacted mandatory patient staffing ratio legislation, sponsored by the California Nurses Association, in 1999. The law included strict UAP job description guidelines that eliminate procedures normally done by nurses. These procedures include venipuncture, tube feedings, invasive procedures (including insertion of nasogastric tubes, catheters, or tracheal suctioning), and/or postdischarge care.16 Consultant Marie Manthey, RN, MSN, states that the most effective use of an auxiliary partner is when that role can do 75% of what the RN can do. Then a group of responsibilities can be delegated, rather than an isolated task. She advocates the increased use of licensed practical nurses, partnered consistently with the same RN.8 However, many ED managers report underutilization when persons in higher trained assistive roles, such as a respiratory therapist, replace RNs.17
Zimmermann/JOURNAL OF EMERGENCY NURSING
Consider mandated staffing ratios. A controversial suggested solution is that of the California legislation, which requires a minimum, specific, licensed nurseto-patient ratio for all acute care hospital units.16 More than 20 other states are considering similar legislature. Some oppose this approach because they fear that minimum staffing levels will become the ceiling. This situation could possibly lead to required staffing numbers that are unsafe at times. An involved trauma case may require a number of RNs. Other factors, such as skill mix and staff competency, are also considerations. Recruit from other countries. Nearly 1 in 10 Canadian nursing graduates from 1995-1997 migrated to the United States.18 Recruiting hospitals report that these nurses are well-trained, have excellent skills, and easily adjust to the differences in our health care system.8 Long-term approaches Reconsider how nurses are being used. Consultant Holly A. DeGroot advocates examining to what extent nurses are spending their time nursing. For example, one ICU had a staffing ratio of 1:2, but the RNs spent less time on direct patient care than did RNs on other units because they lacked supportive systems, such as unit clerks and equipment delivery. Documentation is another time-consuming task. Nurses in one emergency department spent the equivalent of 6.8 full-time employees per day (eg, 54 hours) on charting.8,19,20 From a different angle, consultant Cavouras suggests including unit clerks and assistive personnel in the hospital’s float pool. Otherwise, the temptation to “just send a nurse” occurs when the staffing need could often be met adequately by someone with less training.8 Accommodate the older worker.4,7 Keeping older nurses working in the hospital, even part time, provides staff and experience. Human Resource Director John Vicik advises changing job descriptions, benefits, schedules, training, and recruitment to accomplish this goal. He suggests the following: 1. Create a descending clinical ladder, allowing nurses to fill positions with less responsibility for less compensation, similar to what is done in Japan. 2. Offer benefits that older workers typically value, such as vision care or shorter shifts, rather than child care. 3. Accommodate normal aging changes, such as having training materials in larger print on nonglossy paper.
4. Recruit in senior citizen centers and churches instead of the classified ads, which most older workers do not read. Cavouras reports that a lift team has been a tremendous source of satisfaction at one rural hospital. A team of young employees and a mechanical lift, instead of “greying” nurses, provide this physical service for heavier patients.8
One ICU had a staffing ratio of 1:2, but the RNs spent less time on direct patient care than did RNs on other units because they lacked supportive systems, such as unit clerks and equipment delivery. Reexamine registered nurses’ wages. Nursing wages have basically remained flat in the environment of a growing economy.9 Nursing experience and education are not appropriately rewarded. Just as teachers have clamored for fair compensation for their work, nurses need to insist their vital work be adequately rewarded financially. Begin active recruitment among untapped adult candidates. The profession often overlooks traditional but promising sources of future nurses. Many current, non-nursing hospital employees chose to work in a health care environment because they enjoy helping others. Having a local college’s nursing program recruit right at the hospital is an effective technique. Many recent immigrants see nursing as offering a higher entry-level income than most other associate degree–level opportunities. English as a Second Language classes or ethnic cultural centers are prospective places to begin to foster an awareness of the opportunities available in nursing. Improve nursing’s image. When nurses are not able to give adequate care, it is important to convey that. One floor’s staff even wrote in large letters across the patient identification board, “We are not able to give good care today because we are short staffed.” Even in trying times, most nurses can recall meaningful moments of touching another person’s life. Few professions offer such immeasurable
December 2000 581
JOURNAL OF EMERGENCY NURSING/Zimmermann
rewards. Nurses need to emphasize these rewards when talking with the public. Also, continued vigilance for accurate media portrayals, such as a recent mobilization against one company’s ad that portrayed a nurse as scatter-brained, is important. Instill the nursing vision in young children. Positive contacts with children can be initiated with activities ranging from teddy bear clinics to school visits. Many of today’s nurses recall the impact of an impressionable story or encounter on their own lives.
A call to nursing’s roots A range of opinions about what can be done to address this pending nursing shortage exists. The answers are still evolving. However, no expert suggests replacing the trained, educated, socialized RN with a piecemeal distribution of tasks to lesser qualified UAPs. Repeated studies show that such actions have a negative impact on quality patient care. Decreases in RN staffing coincide with a rise in hospital errors, infection rates, and readmissions. The higher ratio of RNs to non-RNs, specifically the RN hours of care per patient per day, has been proved to improve patient care outcomes.21-24 Editor Leah Curtin sounds the summarizing theme by calling nurses back to their roots. Nursing is a profession which, by definition, focuses on helping and giving. The emphasis of nursing is not business, which is a focus on production and profits. In the end, stressing nursing ideals will help restore the magnetic pull to its life-changing work.25 References 1. Curtin L. A crisis in the making: key facts. CurtinCalls 1999;1:15. 2. Silvestri GT. Occupational employment projections to 2006. 1997, November. Monthly labor review. Washington, DC: Bureau of Labor Statistics. 3. Sloane M. Survey says…more nurses needed. Nurs Spectr 1999;12:16. 4. Zimmermann PG. Healthcare institutions get out of the box and on the edge with the nursing shortage. Nurs Spectr 2000;13:28-9. 5. Jacobs C. Kaiser’s workforce initiative. CurtinCalls 1999;1:7-10. 6. Berens M. Training often takes a back seat. Chicago Tribune 2000 Sept 11;Sect. 1:1, 6, 7. 7. Vicik J. Recruitment/retention. In: Zimmermann PG. Manager’s forum. J Emerg Nurs 2000;26:367. 8. Zimmermann PG. Manager’s forum. J Emerg Nurs. In press.
582 Volume 26, Number 6
9. Berens MJ. Nursing mistakes kill, injure thousands. Chicago Tribune 2000 Sept 10;Sect. 1:1, 20, 21. 10. Labarre L, Jones S. Recruitment/retention. In: Zimmermann PG. Manager’s forum. J Emerg Nurs 2000;26:363-7. 11. Lawrenz Consulting Group. 2000 Staffing survey results. Perspect Staffing Scheduling 2000;19:1-6. [The Perspectives on Staffing and Scheduling is a bimonthly publication of Lawrenz Consulting, 9012 N Cobre Drive, Phoenix, AZ 85038; phone (602)788-0027.] 12. Coburn E, Sinois W. A lifestyle how-to for night-shift nurses. Nurs Manage 2000;31;28-9. 13. Wuerz RC, Milne LW, Eitel DR, Travers D, Gilboy N. Reliability and validity of a new five-level triage instrument. Acad Emerg Med 2000;7:236-42. 14. Wuerz R, Travers D, Gilboy N, Yazhari R, Eitel D. Implementation of five-level triage at two university hospitals. Poster at Society for Academic Emergency Medicine Annual Meeting, San Francisco, CA, May 2000. 15. Travers DA, Waller AW, Bowling JM, Flowers DF. Comparison of 3-level and 5-level triage acuity systems [abstract]. Acad Emerg Med 2000;7:233. 16. Farella C. California staffing law gains national attention. Nurs Spectr 2000;13:11. 17. Griswold A. In: Zimmermann PG. Manager’s forum. J Emerg Nurs 1997;23:641-2. 18. Pond C. Northern exposure. NurseWeek 2000;13:1, 31. 19. DeGroot HA. Patient classification systems and staffing, part 1: problems and promise. J Nurs Adm 1994;24:43-51. 20. DeGroot HA. Patient classification system and staffing, part 2: practice and process. J Nurs Adm 1994;24:17-23. 21. Blegen MA, Goode CJ, Reed L. Nursing staffing and patient outcomes. Nurs Res 1999;47:43-50. 22. Kovner C, Gergen PJ. Nursing staffing levels and adverse events following surgery in US hospitals. Image J Nurs Sch 1998;30:315-21. 23. Bond CA, Raehl CL, Pitterie ME, Franke T. Healthcare professional staffing, hospital characteristics, and hospital mortality rates. Pharmacotherapy 1999;19:130-8. 24. Moore K, Lynn MR, McMillen BJ, Evans S. Implementation of the ANA report card. J Nurs Adm 1999;29:48-54. 25. Curtin L. Mandated ratios in a downsized market [keynote address]. Presented at A Staffing Crisis: Nurse/Patient Ratios [sponsored by CurtinCalls and Cross Country University]; 2000 July 21-3; Washington, DC.
Send descriptions of procedures in emergency care and/or quick-reference charts suitable for placing in reference file or notebook to Gail Pisarcik Lenehan, RN, EdD, c/o Managing Editor; PO Box 489, Downers Grove, IL 60515; phone (630) 6631263; E-mail: [email protected].