Are we spared the worst of the nationwide nurse shortage, or is it rolling downhill at us?
by Barry Henderson
Want to work hard for a living with no holidays, not even Christmas Eve or Christmas Day? Want to put in rushed and hectic 12-hour days routinely, with an occasional "voluntary" but obligatory extra shift tacked on? Like to have people's lives in your hands day and night?
If you have the smarts and the dedication and the youth or vigor that it takes, and that sounds like your idea of a rewarding job, there's a career for you as a registered nurse in a hospital near you.
There are plenty of openings for RNs right here in Knoxville, with virtual assurance there will be even more when you finish school in two to four years and get your license. In fact, the need is so great that working conditions may even improve somewhat by the time you are ready to go to work. Pay, now between $18 and $22 per hour for RNs, should continue to rise.
The shortage of nurses is by no means unique to Knoxville. Many locales, particularly in the country's largest cities and most populous states, are experiencing a critical lack of nurses willing to make the sacrifices necessary to care for hospital patients, even at nearly twice that pay rate. According to Tennessee Hospital Association surveys, Tennessee's statewide vacancy rate in nursing positions tops 10 percent, more than double the 1998 rate. The shortage is worst in Memphis and Nashville. Knoxville hospitals are experiencing vacancy rates at 6 to 8 percent, and are struggling to hold that rate while hoping to reduce it.
Nationwide, the average rate of open positions for RNs is above 11 percent and has reached 30 percent in some hospitals, with the American Journal of Nursing reporting in May a total of 126,000 RN vacancies in hospitals.
California horror stories abound in the industry. Hospitals in the Golden State have been flying in registered nurses from other states to work for only a few days or weeks, with room and meals furnished, at exorbitant rates, just to keep staffing at "adequate" levels. There and in some other places, hospital beds are being kept empty because the nurses are not there to serve them.
So how pressing is the need for more RNs in Knoxville's hospitals? Is patient care here at risk because of the shortage and the required extra workloads? That depends on whom you ask. Hospital administration officials say patients are being well cared for. Nurses and nurse educators aren't so sure, even though most concede that the nationwide shortage has not been felt here as extremely as elsewhere.
At least not yet.
In Knoxville's major hospitals and their networks—Covenant Health, Baptist Health System, University Medical Center and St. Mary's—there are currently about 300 openings for RNs. Those full-service hospitals are filling the open slots on a temporary basis by using part-time nurses who contract for work through agencies, of which there are a half-dozen operating in Knoxville. Still, local nurses say they are stretched to the limit of exhaustion every day.
What's behind the shortage of nurses, and what are the prospects for alleviating it? Metro Pulse asked those questions of hospital personnel, nurses, ex-nurses and educators. The answers form a complex picture of the future of health care in general. The only agreement among all those interviewed is that the situation will get worse before it gets better.
The reasons behind the shortage, which does not appear to be a short-term cyclical event, are varied. First there are external causes not directly connected to the profession itself:
 The population is aging. As the Baby Boomers are moving into their low- to middle-50s, their need for medical services increases concurrently and is expected to keep rising for another couple of decades.
The workforce is also aging; the average age of practicing RNs is now 45. At this age, many nurses are thinking of alternatives to high-stress hospital work. Inevitably, some are taking up other opportunities or retiring.
The workforce coming along behind the baby boom is smaller, meaning fewer replacement nurses are available.
Women, who make up the overwhelming majority of nurses and nursing students, have many more career choices than they did a few generations ago, both before and after entry into the profession.
The sheer number of medical and health care services rendered has mushroomed with increases in medical knowledge and technology, requiring more nursing services and a higher degree of training.
Hospital patient counts are growing, and, because managed care has kept people who aren't acutely ill from occupying patient beds, patients who are hospitalized are sicker, requiring more nursing services and nurse time per patient.
Then there are the reasons nurses have been leaving hospital practice. They are more personal and varied, but they include:
The number of hours they are asked to work.
The lack of flexibility in the 24/7 schedules.
The stress of caring for several very sick patients at any given time.
Increased paperwork.
Other, non-nursing duties assigned to or expected of them.
Increased training and skill requirements without commensurate compensation.
Narrow opportunities for advancement within the profession in the hospital setting.
A May article in the American Journal of Nursing said that, according to a survey, only 63 percent of staff nurses working on inpatient units are satisfied with their jobs. The highest degrees of satisfaction were among younger nurses. The older and more experienced they were, the less satisfied.
Nurses at local hospitals were reluctant to be quoted by name or institution. An agency nurse who worked in Knoxville area hospitals for almost 20 years before walking away, however, put her experiences and her opinions behind her name. Rita Anderson, 50, says her recent work has been limited by her desire to work eight-hour shifts, weekdays only.
"Hospitals don't want eight-hour shifts," Anderson says, "but I want a life."
Anderson says spending evenings and weekends with her nine-year-old daughter is more important to her than steady work. The agency that represents her had found her two suitable shifts in the two weeks before her interview. They paid a higher hourly rate, but she'd have to get in 32 hours a week to qualify for benefits, she says, and that doesn't appear likely right now.
"It's cheaper to hire two nurses than three to fill 24 hours," Anderson says. Those long shifts were part of her reason for leaving hospital nursing. She says that, seven years ago when she got out of hospitals for the first time, "the nurse-patient ratio was bordering on the dangerous. It became a liability issue for me as an RN." She says that made her feel "more vulnerable," and the idea that the hospital she worked for had RNs bagging garbage at the end of their shifts made her feel "expendable." She doesn't want to identify the hospital, but she says the situation was far from unique.
Today, inpatient units are staffed more and more frequently by agency nurses or nurses from an in-hospital pool, who are assigned to different units, sometimes daily, to meet the most pressing need. This practice means that there is often "no continuity, no continuum of care," Anderson says. It also leads to her belief that patient care is suffering.
Not so, says Sam Buscetta, senior vice president for human resources at Covenant Health, which operates Fort Sanders Hospital and five other hospitals in East Tennessee.
"I don't think the staffing levels we have now compromise the quality of care," Buscetta says. He says he believes that there are about 100 to 120 nurse slots open within Covenant, systemwide. Covenant operates the Tennessee Wesleyan College Fort Sanders nursing department with classrooms in Athens and near Knoxville. The college graduated 17 nurses this spring and has about 50 enrolled in its fall class. The company maintains its own agency service locally, strictly to supply its own staffing needs on a temporary, part-time basis. Nevertheless, Buscetta recognizes the longer-term implications of the RN shortage, and his firm has scholarship and loan-forgiveness programs for nursing students.
Richard Hammett, associate administrator of Baptist Hospital, says tuition grants and scholarships are part of his hospital's response to the shortage. "Our biggest competitors [for RNs] are the non-hospital venues, the doctors' offices and the free-standing clinics," Hammett says. "We have to be creative...and flexible in our scheduling." He also says that the big four local hospitals have gotten together to recruit nurses nationwide by setting up joint tables at job fairs.
The collaborating recruiters emphasize the "quality of life" and the amenities and relatively low living costs of the Knoxville area, according to Hammett and two other school administrators—University Hospital's vice president for human resources Betty Gissel and Covenant Health's director of employment services Kay Wright. University, Baptist, Covenant Health and St. Mary's have also each formed a recruitment and retention committee, and regional recruiting has supplied the bulk of new applicants for nursing positions from the seven nursing schools in the region.
"People who apply are looking for very specific things," says Wanda Gibbons, the Baptist system's vice president for patient care. She says working conditions, hours, shifts and specific units are high on applicants' lists. None of the area hospitals are offering the kind of "sign-on bonuses" that some hospitals around the country have resorted to in order to bring nurses aboard. The representatives of the local hospitals say the bonuses, which can amount to several thousands of dollars, would create too much of a morale problem among existing staff nurses.
Like Covenant Health, University Medical Center is looking for about 100 nurses, and Baptist and St. Mary's report RN vacancies running at about 50 or less each. But none of the hospitals' administration representatives say they see a crisis at hand.
St. Mary's senior vice president and chief nursing officer, Trish McDaniel, says her hospitals' vacancy rate for RNs has been "very low" compared with other hospitals across the South. "We're very fortunate," she says, adding that St. Mary's "has spent a lot of effort toward retention [of nurses]."
However, one nurse with more than 15 years in service at another of Knoxville's four major hospitals says patient care there is suffering and is steadily growing worse. "The number of patients [per nurse] is overwhelming, and they are sicker than they used to be," says the nurse, who did not want her identity revealed. "We're always short of help, and our personnel are pushed to the limits. They say there's no mandatory overtime, but they ask you in such a way that you're still obligated." The nurse says critical care units in her hospital are expecting to get by with one nurse for every five patients, when each patient is often in need of a full-time nurse. "When it gets down to five patients and three nurses, they move a nurse to another unit," she says.
Hospital officials don't deny moving nurses around from unit to unit to deal with patients who are in the greatest need at the time. It's called "the acuity system," and it's designed to reassign nurses based on "acute" patient needs. It's also used to assign nurses from a pool of RNs who aren't on a specific unit for that shift. Each of the hospital officials contacted said overtime and extra shifts are strictly voluntary.
Another nurse who is particularly critical of all hospitals and the "not for profit" entities that run most of them also insisted on anonymity. She says the issues are budgetary. She even says she suspects the "shortage" is not a big deal in itself and is just being used as an excuse not to hire more nurses.
None of the national or state figures bear that out. And the local hospitals' recruitment and scholarship programs indicate they are going full-bore after more nurses.
Joan Creasia, dean of the University of Tennessee School of Nursing, says the shortage of RNs is real. She says that a new wave of importing nurses from abroad, particularly the Philippines and Canada, is under way, although "not so much here as in Memphis."
In addition to UT, East Tennessee has four other schools offering bachelor of science degrees in nursing and three that offer associates degrees that qualify their students to take the state licensing exam for RNs. "We don't need more schools," says Creasia, "we need more faculty." She says UT is graduating 100 to 110 new nurses a year, but for both budgetary and competitive reasons, UT can't hire the faculty to instruct more men and women.
"We have more than enough applicants. We have 215 qualified applicants for 108 slots, and we can't fit any more in," Creasia laments. She says that the one positive thing about the shortage is that enrollments, which had been dropping in the '90s, are back on the rise. But schools have not been able to attract sufficient faculty to handle the growth. She says schools have been outbid by everybody in health care for the candidates the schools wish to attract into teaching. Salaries for nurse practitioners, for example, were running almost $25,000 a year higher last year than nursing faculty averages, according to the American Association of Colleges of Nursing. The AACN reported that the nursing faculty average age of 51 means that a flood of retirements is anticipated over the next several years, worsening the situation at a time when more nursing instructors are needed.
The Southern Regional Education Board's Council on Collegiate Education for Nursing lists Tennessee among four Southeastern states projected to lose nursing faculty by more than 50 resignations or retirements in the 2000-2003 period. In a June publication titled "Red Alert," the council points to Tennessee as among six states in the region to have more than 25 unfilled full-time faculty positions when the study began in the 2000-2001 academic year. The regional shortfall in faculty amounted, last year, to about 12 percent.
Unlike RNs, whose numbers are growing slowly across the nation, faculty numbers have actually been in decline. That is a phenomenon that has attracted federal government attention. The Health & Human Services Department released $30 million in June aimed almost entirely at furthering nurses' options for advanced degrees.
Creasia says the UT school got about $80,000 from that pot and expects another boost toward faculty preparation from the Nurse Reinvestment Act, signed by President Bush last week. That act, which authorizes $10 million for 2003 and another $10 million for 2004, allows nursing graduates to repay their student loans by teaching rather than practicing their nursing skills. The money, though, has yet to be appropriated to match the authorization.
Such federal commitments will help. But Creasia and others interviewed—hospital administrators, nurses and educators— see alarming shortages in the number of health care workers needed across the board in the relatively near future.
Nurses comprise the largest numbers, with 2.5 million RNs registered in this country. Eighty-three percent of those are employed in nursing positions, and the U.S. Department of Labor estimates that an additional 450,000 RNs will be needed by 2008.
Meanwhile, the 55,000-member Federation of Nurses and Health Professionals did a survey last year that concluded that half of the nation's practicing nurses were thinking of leaving the profession and that a full fifth say they expect to be doing something else in five years. Three-quarters of those who anticipated leaving within five years could be persuaded to stay if improvements were made to include increased staffing, better hours and better pay, the survey concluded.
Working conditions were cited by virtually all nurses surveyed (and by all of those interviewed locally) as the keys to retention, and the hospitals all say they are working to improve those conditions. But when staffing levels are the most important consideration, when hundreds of thousands of new nurses are needed in only a few years, when teachers of nursing are leaving academic institutions faster than they can be replaced, what is in store for the future consumers of hospital services?
"Some hospitals are really trying to make nurses happy," says Rita Anderson. "The trouble is, they don't have enough nurses, and they're not going to get them. The bottom line is: I love nursing. I just can't do it like they want me to any more."
August 8, 2002 * Vol. 12, No. 32
© 2002 Metro Pulse
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