POLICY/QUALITY: The Nursing Shortage — It’s real

Over at Code: the WebSocket Alwin has a really great article about the nursing shortage called A hard rain is gonna fall. I think he’s right and that after we’ve emptied every third world nation of their meagre nursing supply, we’ll realize that we have do something about it here. And in my view that means training fewer doctors and more nurses instead.

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  1. Ok, as a nurse, I have a whole lot to say about the nursing shortage. I will try to be brief though. First, there is a nursing shortage and it is only expected to get worse in the next 10-15 years as our greying peers begin to retire (the average age of a staff nurse is 47 years old!) Secondly, part of the reason there is a shortage is that there aren’t enough nurses with advanced degrees to teach nursing students (possibly because someone would have to take a $30,000 cut in pay or more to teach?) Thirdly, part of the reason for the shortage is the amount of work that a nurse is expected to do in a 12 hour shift. Try taking care of 5-10 people who are pooping, puking, bleeding, whining, or screaming AND want their pillows fluffed and their sheets straightened. All of this and we have about 3 pounds of paperwork to do while taking care of these people because of all the political bull that goes on, trying to keep our butts covered when people from this lawsuit-happy society decide to sue because they don’t believe that sick people should be allowed to die, lifting 300 pound people because they haven’t taken care of themselves during their lifetime, and still be expected to fetch water and blankets for visitors and family members who call for a nurse when the patient wants his pillow fluffed! Are you hearing me here?
    We need to focus on disease prevention in this country. Families need to take care of their loved ones (fluffing pillows, giving baths, straightening sheets, doing mouth care, wiping forheads, holding the bucket while the patient throws up.) We need to go towards more socialized medicine so that when the person who had open heart surgery and then goes home and drinks, continues to smoke, refuses to exercise or eat properly and has another heart attack won’t be allowed a repeat bypass surgery or intervention because he was noncompliant with care. That in itself would keep a lot of the workload off of nurses.
    I love being a nurse. I love being at the bedside and truly caring for my patient and their family. But because of politics and lawsuits I’m not allowed to do that anymore. I will continue to give the best possible care that I can, but truth be told, sometimes I’m just not allowed to.
    There is no immediate answer for the nursing shortage. Or the physician shortage for that matter. They are thankless jobs these days. We stay in the hospitals through storms, floods, and hurricanes and then we are sued or fired because we leave the hospital to check on our 3 children who we haven’t been able to contact in days because of power outages. We are expected to give of ourselves (doctors and nurses alike) and even risk our own safety, health, and lives. And rarely do we receive a thank you.
    And for those who really think there is no nursing shortage, just go to a hospital and need one. One will come… when he or she can.

  2. I think that hiring foreign nurses could be a way out. Just creat a special programm for nurses from third countries with exams in English and Medicine and find them places to live. That seems real to me.

  3. Okay, I’m going to be deliberately provocative here and suggest that maybe there isn’t a nursing shortage.
    I think it’s a point worth bringing up because Wennberg’s work at Dartmouth seems to demonstrate pretty powerfully that we don’t have a doctor shortage. There are clearly local shortages of primary practitioners in some rural areas and in some inner-city areas, but generally–no. I mean, one of Wennberg’s craziest (and most consistent) findings is that in areas with greater provider density, there is LESS access to care, apparently because as a competitive approach most docs (with the notable exception of family practitioners) super-specialize and cycle through the same small group of patients instead of competing for more patients. There’s no reason to believe that training more docs would solve access problems or improve care, either in areas of genuine shortage or gluts. In fact, there’s a lot of evidence to suggest we’d actually have worse care (or at least spend a lot more money on more intensive treatment and not get better care).
    Nursing shortages I’ll admit I haven’t really looked at, so I’m just speculating based on what I’ve read of doctors. But I’m wondering how much of the nursing shortage is a similar problem. How many nurses are attached to docs who aren’t serving enough people? Also, is there reason to believe that the only reason we need highly trained people (like nurses) to perform certain tasks is that the healthcare system is so dysfunctional that you need to be really well-trained to provide adequate care? Could we partially obviate the need for such highly trained professionals by creating better systems of care?
    I’m wondering how much of this is policymakers’ myopia, and how much of it is a rational (although arguably incorrect) “starve the beast” theory.
    Just thought it was worth putting on the table, becasue the nature of the shortage will determine our response to it. Is it a matter of getting more nurses, or of improving the system so we need fewer? Or something else?

  4. Even though it is the truth and a very serious situation, after reading Tribune-Review’s article “Nursing showing its age,” I sit back and laugh when the colleges and nursing schools say that they are full, all these people are going into nursing. At least half of each class will drop out or flunk out. I would bet another quarter of the class gets the shits of “nursing” within a year or two, and leave the profession to pursue another career. So out of 1,000 potential nurses, I bet 100-200 actually make it a life long career. They keep doing surveys to find out why there is a nursing shortage and no matter how many times we tell them the problems, things never change.
    We’ve heard for years and years, they’ve studied it to death. And for years and years now they have been abusing the nursing staff in nearly every health care setting. The main two causes: (1) chronic under-staffing; (2) undermining most of what they have been taught the minute they are hired for their first job. When it comes to the aides, it’s under-staffing as well as poverty-level wages. The health care industry knows what the solution is as well as nurses do. But if they solved the problem, Doctors or CEOs might have to trade down their Bentley’s for Volvo’s.

  5. Even though it is the truth and a very serious situation, after reading Tribune-Review’s article “Nursing showing its age,” I sit back and laugh when the colleges and nursing schools say that they are full, all these people are going into nursing. At least half of each class will drop out or flunk out. I would bet another quarter of the class gets the shits of “nursing” within a year or two, and leave the profession to pursue another career. So out of 1,000 potential nurses, I bet 100-200 actually make it a life long career. They keep doing surveys to find out why there is a nursing shortage and no matter how many times we tell them the problems, things never change.

  6. I have an aunt who was a nurse. One of the family stories was when she got her first paycheck, she cried because it was so low. She had advanced professional training, but the culture of the workplace didn’t perceive her as a professional.
    Since my aunt took on her first job as a nurse (I’m guessing this was sometime in the 50s), nursing pay has increased and the health care industry has been importing nurses from overseas to meet the “shortfall” (i.e., *demand* that favors dignified treatment of nurses as professionals). Nurses don’t always seem to be up to that status. When my old landlord had pneumonia and needed some immediate help, the nurse took over an hour to get to him. And that was only after his relatives finally got to the hospital and did a better job raising hell than me.
    My thought is both the nursing “shortage” and the poor attitude have something to do with the working conditions. From what I’ve seen, nurses are still treated like unskilled workers. Their managers treat nurses like they are in the army. They are ordered around, monitored closely, and subject to the capricious arbitrary treatment that’s endemic to such “command structures”. The managerial justification is that nurses are sly and lazy and might not earn that big paycheck: but could that same situation simply be subtle reaction to demeaning management? A couple years ago there was a scandal in the Bay Area where one hospital wanted nurses to wear radio tags so their location could be monitored at all times.
    It seems to me that the best manager is the one who starts with, “Would I want to be treated like that?” But perhaps one problem is that too many managers either think they beat the system or they were born into the ruling class: they really think that the people under their supervision are automatons or slaves.
    Some professional areas are starting sunset: various kinds of computer professionals, engineers, and even doctors are being treated more and more like dispensible cogs themselves. Instead of arguing for the protection of their profession and it’s privileges, maybe they should start arguing for dignified treatment of all who have put in the work and made the investment to contribute professional services to the their communities.

  7. Ron- thank you for the nice words.
    The relative shortage of doctors and nurses will worsen as the baby boomers retire.
    The country has a choice: put your faith in the government (a la Kelo v. New London) or in the marketplace (airline prices).
    Government control will allow for real winners (some insurance companies and hospital corporations and some suppliers) and some real losers (doctors and patients).

  8. This whole nursing shortage issue gets back to another issue–when we look at medical issues we look at modifying the current system vs. completely re-engineering it. The ultimate solution may involve changing curriculum, job descriptions, integration of people and technology and service expectations. With job redesign many things currently handled by nurses could be automated, eliminated or delegated to a lesser trained individual? Can patients take more responsibility–as an example some pain management system allow patients to up their dose within limits by pushing a button vs. calling a nurse–how much more of that can built in to hospital beds and accompanying instrumentation? From an engineering/components standpoint, the cost of increasing that type of functionality is very low. Can remote monitoring and point-of-use stocking eliminate the need for nurses in exam rooms–I know at my OB-GYN, the nurse is chaperoning and handing material to the doctor, not performing vital functions during the exam. Can an aging population be brought back to perform support functions in hospitals on a volunteer or part-time paid basis? Remember Gray Ladies and Candy Stripers? Can monitoring technology and remote service delivery technology be combined to allow one nurse to supervise patient care in multiple rooms from a central location (technically even without remote service delivery technology, several lesser skilled people could be supervised by a single nurse with remote monitoring capability). I have a husband with MS and I give him a shot every other day. I’ve had no specialized medical training and we use an auto-inject kit, which has been made so simple the dog could load it and push the button to trigger it. The technology to enable all this is very readily available. The auto-injector we use is reuseable and can be easily re-sterilized. It takes standard syringes and idiot-proofs them. The real question to consider is how many activities per day actually require a fully-trained nurse touching a patient vs. qualified medical supervision of the service delivery process.

  9. Floridians can be pretty funny. In that article above, Scary Numbers, a 58 year old guy is planning his retirement health care costs and he complains:
    “Based on recent experience, I deem the cost of adequate health care to be incalculable – and rising,” said Robert Watts, 58, who runs a Bradenton business publishing real-estate market data. He said a health condition makes it impossible for him to get insurance and he owes more than $100,000 from a four-day hospital stay last year.
    We have a nursing shortage big time here in Florida. The papers are just full of huge hiring bonuses for nurses. I tell everyone to become a nurse and move to Florida and buy a home. It’s reported our housing bubble is stronger than water, soap and air.

  10. I listened to Dr Novacks show on Sunday and he talked about this very subject. He said a lot of the older docs were just throwing in the towel and retiring. The new crop of docs have a very high percentage of women in them. Women have a higher percentage of taking time off to have children. Plus, some return only on a part time basis until their children are grown. Dr. Novack suggests we are going to need more doctors, not fewer, with a population that is growing older.
    Greg Scanlen was a no show on the radio show. But Dr. Novack did a real good job explaining HSAs and the Supreme Courts rulings last week. I think Scanlen must read this blog and chickened out. Dr. Novack could have read from the Saint Petersburg Times Sunday article called Scary Numbers. They wrote:
    * The institute’s projections are hair-raising: Someone who turns 65 in 2015 will need a lump sum of $230,000 to cover health care costs through age 80. Plan to live to 95? Better have $548,000 on hand at 65. And that’s just for one person. Double the number if you and a spouse expect a long life.
    The entire article is here: http://www.sptimes.com/2005/06/26/Business/Scary_numbers.shtml
    Imagine how much a 40 year old couple would need to save for retirement health care expenses. The St. Pete’s Times said there was two ways to cope with these costs. One, a tax free HSA. Two, Tampa Bay housing. No housing bubble here like in CA. Their HSA article was right next to the scary numbers article with charts and graphs becuase you have to be very visual with Floridians. That article quotes Golden Rule saying HSA insurance is 60% cheaper than a $500 deductible and 80% plan that most people have.
    They should have run those articles before the Presidential elections. Now I guess they figure they might as well jump on the tax free HSA bandwagon like everybody else.