A Crisis in Nursing Threatens Patients

California and the nation are in the grips of a nursing crisis that has alarmed caregivers and policymakers alike: Hospitals have turned away patients because of an inability to staff beds or entire wards.

Exasperated with short staffing, mandatory overtime and unsafe conditions, many nurses have chosen early retirement or other work. One medical journal predicts that in 20 years the nation will have 20% fewer registered nurses than needed.

Unfortunately, the hospital industry and some of its allies hope to exploit the shortfall to undermine California’s new law requiring safe nurse-to-patient ratios. In fact, the “safe hospital staffing law,” sponsored last year by the California Nurses Assn., is the type of remedy hospitals should welcome.

The state Department of Health Services is evaluating regulations to establish ratios by January 2002, as required by law. A campaign by the hospital industry to set weak ratios is, at best, shortsighted. Poor ratios would exacerbate the current crisis, endanger patients and drive more frustrated nurses out of hospitals.

The shortage of hospital nurses is largely a self-inflicted industry wound. It was brought about by years of misguided market-based decisions in health care that produced reckless restructuring programs, indiscriminate downsizing, increased patient complaints about the quality of care, deteriorating nurse-to-patient ratios and a marked loss of nurses’ trust in their employers.

Thousands of health care professionals have been laid off. At Kaiser Permanente facilities in Northern California, for example, 1,600 RNs were laid off from 1994 through 1996. A 1997 survey by the California Board of Registered Nursing showed 5% of respondents had left nursing because of downsizing.

Patients and communities were stripped of care statewide. Services were reduced, patients began to experience longer waits for care and, according to numerous studies, there is a rise in medical errors often attributable to chronic short-staffing, fatigued health professionals or other poor conditions.

Growing numbers of RNs decided that they were no longer willing to work in conditions that they believe threatened their patients, their licensure and their physical and emotional well-being. A 1999 study by the consulting firm of William M. Mercer cited a 17% RN turnover nationwide, with 43% of nurses, naming workload and staffing as the reasons.

With health care transformed, the industry and consultants said, fewer nurses would be needed. Hospital-based education and training programs for RNs were eliminated. Nursing schools implemented reductions in education curricula and expenditures. From 1995 to 1998, nursing-school enrollment fell 20.9%, a report by the Harvard Research Institute found. The effects continue.

In late November, the USC School of Nursing, which graduates almost 10% of all registrants who take California’s RN licensing exam, approved a plan to severely cut back or eliminate its bachelor of science degree in nursing.

Although the situation is ominous, it is not irreparable. Earthquakes are natural phenomena. RN shortages are not. What is needed today is not just alarm at the sudden emergence of new RN vacancies, but a change in the practices that led to the shortfall.

Many RNs simply have elected to work in other health care settings with more manageable workloads and safer conditions. California still has more than 250,000 RNs, more than enough to fill hospital vacancies, but the percentage in hospitals has slid steadily in recent years to only about 60% today.

There’s ample reason to believe that more RNs would return to the bedside if hospital-based care was once again the place of safe, therapeutic healing and care that many have devoted their lives to.

Instead of seeking to undercut the governor and the Legislature’s intent in passing the staffing law, hospitals should provide safe staffing levels. Nurses should not be forced to work mandatory overtime when they are exhausted and prone to making mistakes. Hospitals should take other steps to improve working conditions so that experienced RNs will want to stay at the bedside and new nurses will choose to work in the hospital setting.

The hospital industry should join with CNA in encouraging more funding to expand community college and state university nursing education programs and promote and help fund scholarships to encourage the recruitment of underrepresented black and Latino nurses.

As long as the large hospitals continue to put their wealth ahead of our communities’ health, little can be done to restore the trust of nurses in an industry they believe has forsaken them and their patients.