Hospitals Learning to Cope With Shortage of Nurses

Administrators at Holy Cross Hospital in Silver Spring, Md., may be helping to write the handbook on dealing with labor shortages.

At Holy Cross and at hospitals and nursing homes across the nation, managers are coping with what promises to become a growing problem--filling nursing jobs in an era of growing needs and a shrinking work force.

The number of 18- to 24-year-olds peaked early in the 1980s and is expected to decline by 12% over the next decade. For employers, this means a steadily declining number of people will be entering the job market, and many of them will be poorly trained to do the jobs that need filling.

Labor shortages, now appearing in isolated industries and areas, may become commonplace.

In that sense, the reaction of employers to the nursing shortage may provide a sneak preview of what’s to come. Will the labor shortages produce higher wages and stronger unions? More creative management? Sloppier service? An increased dependence on foreign workers?

The reaction to the nursing shortage suggests that the answer may be a combination of those approaches.

Unlike the future labor shortages, the nursing shortage is not the inexorable result of demographic changes. Instead it reflects both a reduced supply of women who wish to enter the profession and a growing need for their services.

Nursing Less Attractive

As new jobs have opened up for women, nursing has become less attractive to women seeking higher pay, more recognition and less stressful work.

“There’s been a major drop in recent years in applications for nursing schools,” said Holy Cross President James P. Hamill, whose hospital has a 17% vacancy rate for registered nurses.

A recent federal study showed the supply of nurses increased by approximately 35% since 1977, although it found signs that this supply is about to contract. It also found that the nurses entering the field haven’t been able to keep pace with demand.

Demand has grown in large part because the patients in hospitals are usually sicker during their stays that used to be the case. Insurance, Medicare and other reimbursement systems, in an attempt to reduce costs, began to limit the number of days of hospitalization that they will reimburse. That means the patients who are hospitalized are there only when their needs are heaviest.

In 1972, hospitals employed 50 nurses for every 100 patients, according to Julia Fry Gibson, director of the Center for Labor Relations, Economic and Social Policy of the American Nursing Assn. By 1986, the ratio was 91 nurses for every 100 patients.

“If you have an appendectomy, you’re only in for four days,” said Gibson. In the past an appendectomy patient might have been hospitalized for seven or eight days, which meant that the patient’s needs had declined substantially by release. “Now they’re there for the four sickest days,” Gibson said.

If demographics haven’t played a major role in the nursing shortage, they may be soon. Not only is the pool of young people entering the work force shrinking, but the fastest growing segment of the population is those 85 and older.

Even without the full impact of those forces, the nursing shortage has reached serious proportions, forcing some hospitals to shut down beds, temporarily close emergency rooms and reschedule surgery.

A recent American Hospital Assn. found a national average vacancy rate of 11.3% for registered nurses. Nearly 80% of all hospitals said they had a shortage, and half of those said the shortage was moderate to severe, according to Carol McCarthy, president of the association.

So how have hospitals and nursing homes responded? One solution has been to pay overtime and to hire nurses from temporary agencies, sometimes paying them more than the nurses on staff. Of the hospitals the association surveyed, 73% relied on overtime to cope with shortages, and 41% employed temporary or agency nurses.

“The reactive response is to try to get people from outside agencies to fill in and to get people to work harder to make up for short staff,” said Gerry Shea, head of the health-care division of the Service Employees International Union. “The second phase seems to be to come to terms with it and try to pay more wages.”

Hospitals have asked to reopen contracts before they expire in an attempt to address the salary issue. And there have been double-digit wage increases for nurses in some facilities. On the other hand, many nurses contend that these increases were on wages that had remained relatively low for the past decade.

In the past, health-care facilities might simply have raised wages and passed the costs on to customers, said Richard Belous, vice president of the National Planning Assn. “That’s Economics 101.” But Belous said recent restraints in the form of both federal and private-sector attempts to control health-care costs have made that harder.

“The bind the facilities are in is they have to rely on the reimbursement they receive,” said McCarthy. That means hospitals, which are “in a state of extreme fragility” already in terms of financial health, have a hard time financing big raises, she said.

Seek Other Solutions

As a result, health-care managers have had to look for other solutions, including quality. “Say there once was a nurse for 15 beds, and now there’s one for every 20 beds; that’s quality adjustment,” Belous said.

Hospitals also have it more difficult because they are less able to turn to automation as a way to remedy the nursing shortage. In fact, health-care experts in many cases say that automation has increased the need for workers.

Nuclear magnetic resonance scanners and the machines that break up kidney stones with sound waves all require additional personnel to operate them, said McCarthy. “They do wonderful things for patient care, but they don’t make us any less labor intensive.”

Hospitals and other industries also have looked abroad for workers. According to the association’s study, 10% of all hospitals have recruited foreign-trained nurses, particularly from such English-speaking countries as Ireland, England and Canada.

Some hospitals have also been trying to make the job more attractive by giving nurses more say in the decision-making process, allowing them to earn more money and take on more responsibility while continuing to work at basic, bedside nursing. In the past, nurses who wanted to advance and earn more money typically had to go into administration, taking jobs that removed them from patient care.

There is also a movement afoot to increase the number of aides, and to experiment with a new job category called a “registered care technologist.” This last idea, however, has created concerns among some nurses that it may be an attempt to take away some of their jurisdiction and give it to lower paid workers.