JUDY BURTON : Suffering a Shortage of Nurses : Redefining Staff Role May Be a Cure, Administrator Says

In her seventh year as executive director of nursing at St. Joseph Hospital in Orange, Judy Burton sets policy and standards for a staff of nearly 1,000 nursing service employees, including about 700 registered nurses.

Burton, 39, has seen the flow of new recruits to nursing sharply decline since she entered the profession in 1973 as an emergency room nurse in her hometown of St. Louis.

Women who once might have become nurses now have a greater opportunity to join other professions that are more financially rewarding--including becoming physicians.

As a result, St. Joseph and other hospitals find themselves competing for a diminishing supply of nurses. Burton said that while St. Joseph does not now suffer a significant staffing shortage, it must constantly ward off attempts by other hospitals to woo its nurses away.

To compete, Burton believes that St. Joseph must improve wages and benefits while continuing to offer good working conditions. At the same time, however, she is aware that St. Joseph, like other hospitals, is under increased pressure from governmental and private providers of medical insurance to reduce costs.

In an interview with Times staff writer Leslie Berkman, Burton recently discussed the causes and consequences of the nursing shortage and how the profession may benefit in the long term from the current situation by forcing hospitals to redefine the role of the nurse.

Q. Has the national shortage of nurses made it difficult for you to keep your hospital fully staffed?

A. I was just filling out a survey for the American Hospital Assn. They asked, “Do you have a minor, a moderate or a severe nursing shortage?” And I checked mild. We definitely have seen signs of a nursing shortage, but we have not been heavily impacted, thank goodness. We’ve mainly had problems filling night shifts. (And) it is more difficult to find nurses to work temporarily when the hospital census fluctuates.

Q. Why do you believe you have not been as severely impacted by the nursing shortage?

A We have a very positive environment for nurses, and we work hard to maintain that environment, in part by making realistic assignments to our nurses. There is a big commitment at the hospital to maintain adequate staffing and appropriate mixes of staff with a high percentage of RNs.

Q. Do you use nurse registries that provide nurses to hospitals for a service charge?

A We used nurse registries only once, in 1986. The major reason we don’t use them is because we like to know our employees and have some feeling for their performance level. Also, we like for them to have a feeling for the hospital. When you use a registry nurse, what you have is someone walk in the door who may never have worked in your hospital before. Even a very fine nurse coming for the first time not knowing our system might have a very difficult time delivering patient care. . . . Also, we want to avoid the high cost of using registries. This year the prices have increased substantially. Today you might pay as much as $42 an hour for a registry nurse, which includes the commission to the agency, to do the same job that the hospital pays its own nurses $15 an hour to perform.

Q. Has the nurse shortage put pressure on the hospital to increase nursing salaries?

A Yes. The demand for nurses has put us in a salary war. We have had several employees receive calls from their former employers, who say: “Come back and we’ll give you 10% more.” We have to concentrate our efforts on keeping the nurses we have. We have to keep up with what is going on out there and then plan strategies to be able to offer nurses whatever it is that will keep them here.

Q. Are your nurses under contract?

A. We have no nurses on contract. They can all leave at any time, with two weeks’ notice for most. For managers, it’s a month.

Q. Isn’t that pretty scary?

A. Yes. In our last nursing shortage, in ’78 through ‘81, 20% of the work force started changing jobs on a regular basis. Not only did that create a shortage, it also created havoc in terms of educating new employees. It costs an estimated $20,000 to recruit and train a nurse to function in a different hospital environment.

Q. How have you seen salaries change for nurses at St. Joseph the past seven years since you became executive director of nursing?

A. Over the last seven years the salary scale for nurses at St. Joseph has increased about 32%. In May of 1981 a nurse on the day shift earned a minimum annual salary of $20,155 to a maximum of $26,770, depending on her experience. Currently, the day shift minimum salary is $25,625 and the maximum is $36,212. In addition, nurses receive higher pay on evening and overnight shifts, and nurses at the top scale can earn bonuses of up to $750 a year.

Q. Is money a significant issue to nurses?

A I think money is a major issue. And I don’t know so much that it’s the entry-level money. More importantly, nurses are seeing other professionals have opportunities to increase their salaries over the years at a much higher rate than nurses. This makes it very difficult to convince youngsters in grade schools and high schools to consider nursing as a lifetime career.

Q. Does this mean also that nurses who want to earn more money must go into another field or become administrators, as you did?

A. Yes. And because of the nature of nursing work, the number of positions in administration are few and far between. So filling those positions with nurses is not the answer. The answer relates more to making the staff nursing role really meaningful, rewarding those folks and giving them the incentive to stay. And money is a big part of it. There are also other issues of autonomy.

Q. What do you mean by “issues of autonomy?”

A Being able to devise and carry out a plan of nursing care within a hospital, as opposed to having a lot of rules and regulations and policies and procedures imposed. I think nurses are asking for more discretion and more involvement in making decisions that affect the workplace and how they do their job.

Q. How do you attempt to make working conditions at St. Joseph Hospital attractive to your nurses?

A. By promoting nursing autonomy and continuity. There is an effort to assign the same nurse consistently to a patient. And we try to minimize the practice of floating, which means shifting nurses from, say, the orthopedic unit to the general surgical unit as the hospital census fluctuates.

Q. Is nursing becoming more specialized?

A Yes. We run about eight internships here in such specialties as critical care, surgery and obstetrics. They are extensive training programs lasting anywhere from six weeks to three months.

Q. Do the internships lead to career advancement and higher salaries?

A Those kinds of transfers are really lateral, and so there’s no extra money to go with specialization per se. But it is an opportunity for a nurse to learn a specialized body of knowledge and to work in an area she otherwise would not be qualified to work in.

Q. Since so many women are admitted to medical schools today, why would a woman decide she would rather become a nurse than a doctor?

A. Because it’s basically a whole different career that offers more opportunity to provide direct patient care.

Q. Do you think you have lost any potential nurses to medical schools?

A Absolutely. The number of women coming up through grade school and high school and entering nursing has plummeted while the number of those entering medicine, as you say, has really increased. There are some medical schools graduating 50% women. Which is fine, as long as nursing gets its share of men so we’re balanced.

Q. Is the number of men entering nursing on the rise?

A Overall, there is a decline in the number of men entering nursing just as in the number of women. Men are less than 2% of the total nursing work force. Men have the same concerns as women about nursing as a career and the potential for salary growth.

Q. When will you next consider raising nurses’ salaries at St. Joseph?

A On a regular basis we look at what is going on in the county and make adjustments. We are putting together our wage and benefit package right as we speak here to present for approval to the hospital Board of Trustees later this month. . . . We change fiscal years in July, when we will be implementing some changes.

Q. Do you expect an increase in nursing salaries?

A Yes. We will definitely increase salaries to compete in the marketplace. I think we will increase salaries overall and also widen the range between the entry and top levels. We have a lot of long-term people here who are at the top of the range. And it is frustrating to be at the top and have nowhere to go.

Q. What percentage of your staff is in that situation?

A I think we have about 25% of our people sitting in that top area who have been here over five years.

Q. At a time when hospital budgets are being squeezed, how do you justify raising nurses’ salaries?

A. Well, I think you must recognize the valuable role that nurses play in the health-care delivery system. But at the same time you must shift non-nursing functions away from registered nurses and to less costly support staff. The nursing shortage will be beneficial to nursing in the long run because it gives us an opportunity to look at ways to give increased status to nurses and to design more effective health-care delivery systems. We won’t have enough registered nurses in the future to meet growing patient care needs as our whole population ages. So we will have to utilize other resources, technicians and aides, to support registered nurses.

Q. What role do you envision for these non-RN hospital workers?

A I think they would be working side by side with RNs, taking direction from the RNs. They might give bed baths and bedpans and prepare dressings. But we don’t want to revert to a system where the RN becomes a figurehead somewhere, and the care is really being delivered by unlicensed personnel. It is my hope that the system that evolves will have RNs doing just what RNs need to do.

Q. Will you be able to find enough nursing assistants to hire?

A I think that’s a problem in Orange County. The cost of living in Orange County is so high that it is harder to find folks willing to work for lower wages. We definitely need to provide training programs for certified nurse aides to increase the labor pool.

Q. Is there anything else you would suggest to help retain nurses without overburdening the hospital budget?

A. Getting away from just increasing salaries, I want to provide working conditions that are supportive of nurses.

Q. Such as child care?

A. Child-care service is a big issue for our nurses. Right now we help our nurses find good child-care services in the community. As time goes on, I think we will probably provide some benefits to offset some of the cost of child care.

Q. Why do you believe there will be more demand for nurses in hospitals when the recent trend has been to reduce hospitalization and instead provide more care for patients in clinics and at their homes?

A. I think the transition from inpatient to outpatient care will level off. What we will see left in the hospital are very ill patients requiring a lot of RN intervention and probably in growing numbers simply because we are an aging population and because technology makes so many treatments available to us.

Q. How long do you foresee the nurse shortage lasting?

A I am of the majority opinion that the shortage is going to go on to the year 2000. We will see more folks entering nursing. But that will be gradual.

Q. Why won’t the law of supply and demand solve the nurse shortage more quickly? In the past when there was a shortage of engineers, engineering schools quickly filled up.

A. Because I think that historically the opportunity for women to enter other professions did not exist. Many women who would have entered nursing in the past because of a lack of options now are going on to other professions. That is not going to change. We came out of the previous ’78 to ’81 nurse shortage with a relative degree of quickness because entry into the profession really picked up when the shortage began. I don’t think that’s the case now. I think we’re seeing declining entry into the profession despite the demand for nurses.

Q. Has an influx of foreign nurses, especially from the Philippines, helped to alleviate the nurse shortage?

A. Although St. Joseph has not purposely gone about recruiting foreign nurses, other hospitals in Southern California have, and a result is that there are a number on our staff. They are well-qualified, and we have been providing English and communications classes for them.

Q. Are you pleased that you chose nursing as a career?

A I am. I love nursing, and it has afforded me a lot of opportunities. I made a career decision almost seven years ago now to get an MBA instead of a master’s in nursing. And it has given me a chance to learn the business side of the profession, which has been really challenging.

Q. If you were a patient today in a hospital, would you be concerned about the nurse shortage?

A. I sure would if I was in a hospital where they didn’t have sufficient nurses. Nursing care is, you know, the primary work of a hospital. So yes, I would be concerned about that as a patient. And I think people are more and more concerned about it.