The sad state of healthcare staffing

This is an old, old, article (published some time in February 2001) I believe. I don't have a link to the original publication and I'd appreciate it if someone could let me know if they do.

Not only is the article bang-on-target, it's ominous that in the 6 years since it's publication, the conditions haven't changed for the better.

In fact, they've gotten worse.

The Sad State of Healthcare Staffing



Night after night, registered nurse Julie Ginther finds herself at ground zero in the national nursing shortage. One recent evening, Ginther was responsible for six patients recovering on the postoperative floor at Menorah Medical Center in Overland Park, Kan. The patient load was two more than Ginther deemed safe, and she was worried she wouldn't be able to keep up.

Her concerns proved justified. A few minutes into the shift-as Ginther helped an 80-year-old man to a bedside commode-she was informed that a patient in her 70s, confused by anesthesia, had climbed out of bed. Ginther rushed to help the woman but was unable to respond to a concurrent call from another elderly man recovering from abdominal surgery. Meanwhile, the patient she'd helped to the commode was dutifully waiting for assistance in getting back into his bed, a task Ginther couldn't accomplish without help.

Finding her co-workers equally stressed, Ginther raced off the floor to get a supervisor to help her lift the man up. Only then was she able to respond to the third patient who'd rung for help some 15 minutes earlier. By that time, the man had relieved himself in bed.

"How would you like it if that was your father, or husband or grandpa, sitting in his own urine and waste?" Ginther says. "Because he had an abdominal incision, it was a major infection concern. But if I hadn't gotten to the woman who climbed out of bed in time, she could have fallen and broken a hip or opened her incision. You run from fire to fire all night long."

By all accounts, Ginther's precarious work environment is increasingly the rule nationwide, as nursing's thin white line buckles under the combined weight of long hours, low pay and little respect. Yet as serious as the problem is, experts warn that the nursing shortage is only the most visible piece in a broader healthcare staffing crisis that, if left unchecked, threatens to implode the country's delivery system in the coming years.

Hospital and health plan executives say worsening shortages are being felt at nearly all points along the continuum of care. Nurse's aides, nurse anesthetists, radiology and nuclear medicine technologists, lab techs and respiratory therapists-not to mention food service and maintenance help-are all in short supply. So too are pharmacists, who are abandoning careers in acute care for other opportunities, as well as anesthesiologists and other specialists, whose importance was mistakenly de-emphasized during the healthcare reform upheaval of the mid-1990s.

In a recent survey of nearly 500 acute-care hospitals conducted on behalf of the American Hospital Association, 62 percent of respondents said that personnel shortages had increased either somewhat or dramatically from a year earlier. Another AHA study showed 126,000 nursing vacancies at hospitals nationwide. The problem is being similarly felt in home health and nursing home care. But while the industry as a whole is mobilizing in search of solutions, few observers expect the overall employment crisis to pass anytime soon in a sector that employs nearly 14.6 million people, or slightly more than 10 percent of the U.S. workforce.


Grim Outlook

His is going to get worse," predicts Greta Sherman, senior partner with the Healthcare Group of Louisville, Ky.-based JWP Specialized Communications, an employment consulting firm. "I've been doing this for 25 years, I went through the nursing shortages of the '70s and '80s, and I've never seen anything even come close to what we're facing now. I'm 49 years old and I don't want to get sick. It scares me to death."

In the broadest sense, the staffing shortage is the latest side effect of healthcare's awkward transformation from a somewhat insular cottage industry into one that's increasingly susceptible to the market forces that impact nearly every other business sector. But now the competition is not only among providers themselves but with other industries as well, and the prize is not new business but employees. After profiting for generations from a steady supply of female employees with few other avenues of employment, hospitals and other healthcare organizations now find themselves unable to compete with a wide-open universe of work opportunities for women.

The situation is worsened by a complex web of cultural, economic and demographic factors. Relentless financial pressure at the provider level is not only containing salaries but increasing the workload for a broad range of clinicians. The resulting turmoil has made it harder to recruit new workers and has triggered an exodus of the veteran staffers who've carried the industry for years, a situation that further increases the burden on those who remain.

"It's a pretty pathetic situation," says Michael Morrissey, a veteran respiratory therapist at St. Francis Memorial Hospital in San Francisco. "We're very short-staffed. Nobody wants to become a respiratory therapist anymore, basically, because you can make more money going into computers or some other line of work where you don't get coughed on or spat on. It's just a dirty job and nobody wants to do it."

Making matters worse is the steady shift from inpatient to outpatient treatment, which means that only the sickest of the sick are now cared for in the hospital setting. This, too, increases the responsibilities and stress on a clinician pool that is already approaching its limits.

Finally, the worker shortfall comes as upwards of 80 million baby boomers inch toward old age, ill health and infirmity. And because the shortages stretch far backward into the educational pipeline-and thus will take years to rectify-the problem extends over the horizon and beyond.

"The demands for higher acuity healthcare will intensify significantly over the next decade," says John Leifer, CEO of the Leifer Group, an Overland Park, Kan.-based healthcare consulting firm. "At the same time, we're at a point of unparalleled cost restraint within healthcare, and a resulting decline in the economic health of the nation's provider organizations.

"Add to that an increased demand for quality healthcare by payors, businesses and consumers, along with the recognition that medical error is an enormous problem that needs to be rapidly mitigated," Leifer declares, "and all in all, I'd say you've got a pretty ugly situation."

Delays, diversions, low pay

Just how ugly can be seen in New York, one of the states hardest hit by the worker shortage. Daniel Sisto, president of the Healthcare Association of New York State, says he's increasingly hearing of surgeries postponed or delayed and hospitals sending ambulances away due to the worker shortage (see sidebar).

"Between 80 and 90 percent of our members are reporting significant vacancies, whether it's RNs, LPNs, nurse's aides or technicians," Sisto says. "The fact is, I don't believe any hospital CEO in New York state can assure the public that optimum quality of care is being delivered now. And that's not something I'm proud to say."

Staffing vacancy rates-particularly for nursing positions-are exceeding 20 percent in some areas, up from traditional levels of less than 10 percent, notes Peter W. Butler, CEO of Methodist Health Care System in Houston and chairman of an American Hospital Association initiative charged with addressing the problem.

"Unlike previous shortages, where you could anticipate a recession and those that were on the sidelines would come back, there really aren't any on the sidelines now," Butler says, noting that a wide range of alternative employment opportunities exists not just in healthcare, but in any number of more lucrative and less-stressful fields. As for money, most providers don't have enough to compete effectively in the still-powerful economy. In 2000, nurse salaries averaged $46,782, up from $42,071 in 1996. When measured against inflation, however, salaries for nurses have remained nearly flat for 20 years, according to the U.S. Department of Health and Human Services' Bureau of Health Professionals.

Yet for the 60 percent of the nation's 2.6 million RNs who work in acute-care settings, the money is apparently less important than the arduous conditions of the job itself.

"I've left work sometimes and my feet hurt so bad they don't stop hurting for two days," says Leslie Remington, a Kansas City, Mo., nurse. "Twenty-year-old nurses are getting back injuries, and people are going for 12 hours without even being able to go to the bathroom. It's the slave labor conditions that are the real problem."

According to a recent survey of 700 current and former nurses conducted by the Federation of Nurses and Health Professionals, an AFL-CIO-affiliated union, 84 percent of those surveyed said they believe there is a moderate or severe nursing shortage. Half of the currently employed nurses said they've considered leaving the patient-care field, and 20 percent said they plan to quit soon. The primary reason cited for leaving, or contemplating it, is the desire for a lower pressure and less physically demanding job. Of the respondents, 56 percent gave job conditions as the biggest problem, versus 18 percent who cited compensation.

Education catch-22

The current reality is that there are not enough newly trained nurses waiting to take the places of all of those running for the exits. The American Association of Colleges of Nursing reports that enrollment in nursing programs has fallen by a cumulative total of 25 percent over the past six years, with no reversal of the trend in sight.

The growing reluctance to pursue a patient-care career is reflected in the advancing average age of nurses nationwide. According to the Bureau of Health Professionals, the average nurse was 45.2 years old last year, nearly a year older than in 1996. Significantly, only 31 percent of nurses today are under the age of 40, down from 53 percent in 1980.

"Potential students don't see nursing as the most attractive career," says Polly Bednash, Ph.D., R.N., executive director of the American Association of Colleges of Nursing. "At the same time, we're having difficulty getting enough faculty in the schools. It's quite a complex problem."

Given the current educational and demographic trends, government experts warn that by 2020, there will be a shortage of 400,000 nurses nationwide.

Bednash acknowledges that part of the problem is the competing tracks that nurses can pursue to earn a nursing degree. Currently, nurses receive comparable R.N. licensure through either a two-year associate degree or a four-year baccalaureate degree. Yet typically, getting a four-year R.N. degree doesn't translate into much higher pay. Hence, students who are committed to a full four-year college education are less inclined to enter a profession where an additional two years of training doesn't mean greater earning power.

"If you look at medicine, dentistry and veterinary medicine, the number of women entering those fields has gone up tremendously," Bednash points out. "The people who used to come into nursing are choosing other fields that more clearly reward a better education."

Grueling, stressful work

The same core issues that are undermining the nursing workforce also are affecting a range of other clinical occupations. Hard, stressful work and a multitude of employment alternatives are taking a toll on therapist, aide and technician positions. In fact, in AHA's recent survey of member hospitals, 71 percent of respondents reported that their greatest workforce shortage was in radiology and nuclear imaging.

Mark Bakken, chief operating officer of U.S. Radiology Partners Inc., an Irving, Texas-based radiology management and services firm, says the imaging technician shortage is being fueled in part by the surging growth in the volume of clinical imaging, which is increasing at about a 13 percent clip annually nationwide.

In a recent study of Colorado's impending worker shortage by the U.S. Department of Health and Human Services, the agency predicts that by 2006, Colorado will need 80 percent more physical therapists, 73 percent more emergency medical technicians, 62 percent more occupational therapists, and 56 percent more home-health aides.

At the same time, a shortage of pharmacists continues to plague acute-care providers across the country. HHS's Health Resources and Services Administration says the number of unfilled pharmacist positions nationally rose from approximately 2,700 in February 1998 to nearly 7,000 by February 2000.

Mary Anne Koda-Kimble, dean of the School of Pharmacy at the University of California at San Francisco, attributes the shortfall to the exploding array of expanded, high-paying pharmacy opportunities in both retail and managed care, as well as a dramatic increase in the overall volume of prescriptions. And as in nursing, there has also been a sharp decline in the number of pharmacy school applicants, with the numbers in 1999 down 33 percent from 1994, according to the Health Resources and Services Administration.

Moreover, she says, the job has become considerably more complex and demanding than it used to be.

"There are more new drugs, more complex drugs, and the way they must be administered is much more complex," she says. "There is a growing trend toward combined drug therapy, which requires multiple medications working in unison and means a greater likelihood of drug interactions and side effects."

Even as many patients are taking greater responsibility for their healthcare, the need for pharmacists to provide them with consultative services is more critical than ever. Yet most pharmacists have far less time to play that traditional role, Koda-Kimble says.

On the physician front, an anesthesiologist shortage is forcing some operating rooms to shut down and some surgeries to be postponed, observers say, although no statistics are yet available.

According to Armin Schubert, M.D., chairman of the Department of General Anesthesiology at the Cleveland Clinic Foundation, only 390 anesthesiology residents who graduated from U.S. medical schools finished their training last year, compared with 1,500 in 1995.

"I hear reports from virtually all over the nation that operating rooms remain closed that would otherwise be open, and that pain management practices are being closed or limited," Schubert says.

Gregory Unruh, M.D., an academic anesthesiologist at the University of Kansas Medical Center and chairman of the American Society of Anesthesiologists' Physician Resources Committee, attributes the shortage to a sharp decline in the number of students who pursued the specialty in the mid-1990s.

"There was the perception that with the shift toward managed care, we wouldn't need nearly as many [anesthesiologists]," Unruh says. "Of course, that's proven not to be true."

Schubert adds that with salaries climbing, he's confident market forces will eventually rectify the shortage as more students select the specialty. It's the next five to 10 years that has him worried.

"My concern is that with a limited labor supply, there will be limited growth in surgical medicine and that means access to care will be limited," he says. "We're already seeing this in terms of waiting periods for some elective surgeries. It's kind of frightening, but I don't see any immediate solution because people still aren't coming into the specialty at a very high rate."

Even graver concerns surround radiology, which, like anesthesiology, saw a sharp decrease in residents during the healthcare reform tumult of the mid-1990s. Though residency programs are beginning to fill back up, the problem will be made much worse in the near term due to a 1997 decision by the American Board of Radiology to require that diagnostic radiologists complete a one-year internship in addition to their four-year residency.

"That means that next spring, there will literally be no new residents coming out," says Lori Boyd, director of administration for the American Board of Radiology. Bakken of U.S. Radiology Partners assesses the situation this way: "The impact will be massive, but most people I talk to-administrators and heads of radiology and imaging groups-have no idea this is going to happen. I feel like Noah before the flood."

Bakken predicts that the shortage will quickly become acute, and that over the next seven to 10 years it will probably lead to the closing of many small, rural hospitals that are simply unable to attract radiologists.

"A hospital can function without an extra surgeon, but without a radiologist or access to interpretation of images, it cannot exist," he warns.

Beyond anesthesiologists and radiologists, other physicians predicted to be in short supply as baby boomers enter their twilight years are a variety of intensive-care physicians. These specialties include pulmonologists, cardiologists, gerontologists, urologists, obstetricians and cardiologists.

Mark Kelley, M.D., CEO of Detroit-based Henry Ford Medical Group and executive vice president and chief medical officer at the Henry Ford Health System, recently co-authored a study concluding that a shortage of pulmonary critical-care specialists will get progressively and substantially worse across the first three decades of the century.

"By 2010, we won't have enough people to provide even the critical-care levels that we have now," Kelley says.

According to the study, published in the Journal of the American Medical Association in December 2000, the overall shortage of ICU specialists will mean a shortfall of 22 percent of demand by 2020 and 35 percent of demand by 2030.

"I think our paper should be a wake-up call to the public-policy makers," Kelley says. "They had better start paying attention to this, because you don't just throw a switch to get these kids trained to be critical-care specialists."

Seeking relief

Butler, the CEO of Houston's Methodist Health Care System who is heading up the AHA's workforce commission, says efforts to address the overall problem are proceeding on two tracks: An external advocacy effort is aimed at alerting political leaders to the implications of the current trends and developing legislative initiatives to address them. At the same time, an internally focused effort is concentrating on pushing the structural and cultural changes necessary to improve the work environment in healthcare.

Butler believes there is growing recognition of the problem in Washington, and several bills have recently sought to address elements of it. In early April, two bipartisan bills aimed at reversing the nursing shortage were introduced in the Senate and a companion bill introduced in the House. The Nurse Employment and Education Development Act, sponsored by Sen. Tim Hutchinson, R-Ark., would authorize $105 million in fiscal 2002 to fund a variety of nurse-training, education and scholarship programs.

"The educational system has to have the capacity and attractiveness to bring people into the field, and that will require support from elsewhere," Butler says. A number of bills pending both at the federal and state levels, he notes, would attempt to increase the size of the labor pool. On the internal front, Butler says it's going to require bold, creative thinking and real action to reverse the growing perception that healthcare is a less-than-desirable career path. "Some of these ideas may not be all that attractive to our members," he acknowledges.

Sisto, president of the Healthcare Association of New York State, agrees that fundamental cultural changes, many of which may be unsettling to providers, need to occur within hospital organizations in order to turn the tide.

"Something we've tried to pound into our administrators is the fact that the view patients have of their hospitals is going to be based on how they felt nurses responded to them," says Sisto, who's been instrumental in assembling the broad-based Workforce Investment Now Coalition in New York to address the state's staffing shortages.

"If the nurses are feeling good and they're energetic and delivering attentive care, then you've got a great hospital. If the nurse comes in and says, 'You won't believe the terrible conditions in this place,' then the person is going to believe their stay was poor, regardless of the outcome.

"So we have to give nurses a decent environment to work in, we have to retain the staff we have, and we have to attract older workers, retirees-not only nurses, but firemen and policemen or others who are considering a second career in their 40s or 50s," Sisto says.

Bednash, of the American Association of Colleges of Nursing, agrees that nurses are at the core of the acute-care experience and should be treated as such.

"If you go into a hospital and stay overnight, it's for one reason only," she says. "It's because you need sophisticated skilled nursing care to support you in your recovery process. That's the only reason people get admitted to hospitals. And until hospitals understand this, nurses will not be valued, and they'll continue to be treated as though they were janitorial staff."

Bednash adds that history has made her skeptical about how much real change will occur as a result of the current crisis.

"It's déjà vu all over again," she says, noting that in the last major nursing shortage in the '80s, hospitals did make changes that included more money and more autonomy or authority for nurses. But hospitals soon grew complacent, she claims, and began worrying more about the bottom line and less about maintaining morale. The result was layoffs, along with reductions in the governance role of nurses.

"In many cases, senior expert-care nurses have been laid off, and the organization culture that kept nurses happy has been destroyed," she says. "And now the hospitals are crying that they're having problems."

James Barba, chairman and CEO of Albany Medical Center, acknowledges that providers must take some of the blame for the current situation.

"Certainly, healthcare has not been as efficient, generally, in terms of business practices and the delivery of care and the bottom line as other industries," Barba says. "And now it's our turn. The problem is that we find ourselves at an enormous disadvantage, since 60 percent of the revenue stream of this particular institution comes from government, and we have no way to negotiate or bargain with the government on those rates."

Barba believes that ultimately, reversing the current situation will require increases in Medicare and Medicaid reimbursements, as well as a massive effort to warn the public of the looming train wreck up ahead.

"It is inconceivable to me, quite frankly, that the American public will put up with this very long, once they understand that if one of their loved ones needs to go into a hospital, they may not be able to."

Bonar Menninger is a freelance writer based in Kansas City.

"It's Getting Worse, Not Better" One hospital's daily struggles with staffing shortages To understand the impact of the healthcare worker shortage, look no further than the emergency department at 500-bed Albany Medical Center in upstate New York.

On any given day, up to a dozen patients in the department can typically be found parked in hallways on gurneys, waiting for hospital beds. The problem isn't the availability of beds, but the inadequate number of nurses and other clinicians to provide the care. Albany Medical Center serves 3 million people across eastern upstate New York and western New England. "It's getting worse, not better," says Lynne Longtin, R.N., the medical center's patient care services director. "Closing beds is not part of our plan right now, but that's a realistic possibility if we're unable to staff them."

Vacancy rates are the highest-upwards of 20 percent-in the departments with the sickest patients, according to Albany Medical Center chairman and CEO James Barba. When the ER is full and patients need immediate treatment, Barba adds, Albany uses its helicopter to transfer the patients to other regional tertiary-care centers that are less understaffed.

Beyond the backlog in the emergency department, the difficulty of maintaining a full staff throughout the hospital has forced Albany to postpone elective surgeries. Although the postponements so far have been relatively infrequent-perhaps one or two per month-it's nonetheless a growing problem, Longtin says.

The arduous working conditions nurses face at the hospital have also sparked labor organizing efforts. Last year, a proposal to unionize the facility's nurses was defeated by only one vote. "I think it's discouraging that the nurses are choosing to partner with the union to remedy the situation, rather than to work more actively with both the government and with us," Longtin says. While the shortages are most serious in clinical areas, even janitorial and food-service workers are hard to find.

"In this region of New York state, we have virtually full employment," Barba points out. "And the starting wage at fast-food restaurants around here is $8 to $9 per hour, with full benefits. We just can't compete with that, so we're losing out on entry-level workers."

Barba says a solution to the growing staffing crisis must begin with further restoration of the 1997 Balance Budget Act's Medicare cuts, along with increases in state Medicaid reimbursements. In addition, he says, a comprehensive national plan must be developed to address the expense of caring for the uninsured. Last year, Albany Medical Center spent more than $20 million on uncompensated care.

"The responsibility for providing that uncompensated care belongs to the government, or to society as represented by government," he says. "But it does not belong to Albany Medical Center."

Ultimately, Barba believes, solving the worker shortage will require the equivalent of a "Marshall Plan" for healthcare.

"It amazes me that we could develop a tax cut program of more than $1 trillion in only a few weeks in this country, or that we could suddenly make education our number one priority, basically in the space of a single presidential campaign," Barba laments, "yet no one is paying attention to the enormous problems in the healthcare industry."

-Bonar Menninger

Nursing Home Needs

The recruitment of nursing personnel could become increasingly problematic for nursing homes unless there are substantial changes that address the systemic problems in long-term care. As the need for long-term care services increases over the years-due in part to the aging baby boomer population-the proportion of available nursing personnel needed in nursing-home settings increases.

The need for RNs in nursing homes is expected to increase 66.1% between 1991 and 2020. The need for LPNs in nursing homes is expected to grow by 71.5% from 1991 to 2020.

The need for nursing aides in nursing homes is expected to grow by 69.1% during the same period.

At the same time, the government's calculation of nurse staffing availability is not encouraging, and questions remain as to whether the supply of nurses will meet the demand. The U.S. Department of Health and Human Services projects a 14% shortage of nurses nationwide by the year 2020. Other research has projected a shortage as great as 20% by the year 2020.

SOURCE: American Health Care Association, February 2001

So, the next time you hear some politician flap his lips about "Health care reform", see if he addresses this issue.