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HOSPITALS: Why We Don‘t Have Enough Nurses (It’s Not Low Wages) By Maggie Mahar

THCB contributor Maggie Mahar returns today with another of her insightful pieces on the business  of healthcare. If you haven’t yet done so, you are hereby commanded – yes, as in that’s an order – you should go pick up your copy of Money Driven Medicine: The Real Reason Healthcare costs so much, Maggie’s recent study of the forces at work in the  healthcare marketplace.

Consider
this: In the San Francisco area, a nurse with a bachelor’s degree can
hope to start out with a salary of $104,000. The salary for a nursing
professor with a Ph.D. at University of California San Francisco starts
at about $60,000.

This goes a long way toward explaining why nursing schools turned
away 42,000 qualified applications in 2006-2007—even as U.S. hospitals
scramble to find nurses. We don’t have enough teachers in nursing
schools and the fact that the average nursing professor is nearly 59
while the average assistant professor is about 52 suggests that, as
they retire, the shortage could turn into a crisis. The most recent issue of JAMA (October
10, 1007) reports that in 2005 we had 218,800 fewer nurses than we
needed and by 2012, it’s estimated that we’ll be short some 1 million
nurses.

Hospitals have had to raise nursing salaries (as well they should),
not just because nurses are scarce but because, in our chaotic hospital
system, the work can be extraordinarily stressful.   

Nurses know better than anyone just how many “adverse events” occur each day –even in the most prestigious U.S. hospitals.

“I’m terrified of killing someone,” one young nurse confided to me
about a year ago. After working in a hospital in Bermuda for a number
of years, she was bored, and had come back to work in New York, where
she had friends and family. She had worked in New York before, but she
wasn’t at all sure that she would stay. “In our hospitals, it’s just
too crazy,” she said.

Her story also sheds light on why nursing professors are willing to
work for $60,000 a year when they could, no doubt, more than double
their salaries if they were willing to wade into the fray at local
hospitals.

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29 replies »

  1. The patient is a more educated consumer, which is a good thing, but they also dictate to the physician and the nurse the testing and treatment that they would like to get.

  2. We have plenty of unskilled nurses or carers and nursing aids doing short courses to give medications, but a huge shortage of skilled nurses as they cost too much. Perhaps it’s the same in California.

  3. It seems to me there is no shortage of nurses here in California…there is a huge shortage of GOOD nurses…but we plenty of nurses in general.

  4. In my opinion the shortage of nursing has been caused by bureaucratic greed both within the health system and politically. For years nurses have been over worked and under paid whilst administrative staff and doctors reaped the rewards. Nurses were forced to increase their level of education from the early 1990s, but they didn’t receive financial rewards for this; instead they were expected to take on more responsibility and more stress without complaining. Consequently work related injuries and accidents increased. Nurses who were injured doing their job were treated by their employers and work cover as criminals out to make an easy buck, and those nurses who tried to remain at work on restricted duties were frequently bullied by their colleagues who were under the misconception that these injured nurses were just being slack; inevitably the injured nurses was pushed out of his/her job. Work cover then made the life of these nurses so bad that some committed suicide, others couldn’t continue fighting for their rights because of the stress and ended up on welfare payments. Those that did fight on were often left with emotional scars in an injust system.
    As nurses became injured this created a loss of nurses and stress on the system. But other nurses left to raise children and increased the shortage of nurses. The result was that those who remained in the system were under greater pressure as their work load increased (but not their pay); this inturn drove even more nurses out of the industry creating more stress on the system the eventually resulted in the shortage of nurses. The reason it got this bad is due to bureaucratic greed. Money could have been put in to the health system years ago to get proper equipment that would have prevented a lot of back injuries. The sad thing is that this problem still hasn’t been properly addressed and so nurses continue to get injuries. Injured nurses could have been looked after and retrained, instead of being pushed out the system. Sadly they are still being thrown away like disposable gloves. And though nurses’ wages have increased due to the shortage of nurses, the roles and responsibilities of nurses have also increased to a level that continues to show nurses are being underpaid for the work they do.
    Unfortunately this will cause more nurses to leave the industry as the only ones benefiting from the current situation are the bureaucrats who created the problem in the first place.

  5. Hospitals are nurses.
    The reason that there is a nursing shortage is that the nurses are so overworked by the current system that they burn out within five years. if you take into account the number of nurses that have graduated nursing school in the past twenty years you will find that a great percentage of them no longer work in the profession. This has not always been the case. They don’t leave because they don’t like nursing but rather because nurses now care for as many as 18 patients per day in some hospitals…You have to be a top notch athlete to be a nurse. I know this has been true of HCA hospitals. In the late sixties it was not uncommon for a nurse to take care of three patients in a day. They knew them all personally gave sitz baths and were on the spot when a patients condition changed.
    I’ll take a hospital where the money is put into the nursing staff over high tech equipment any day. Nowadays if you leave a loved one in a hospital alone and don’t check their treatment you are almost signing their death certificate.
    NOwadays they train the maid for a couple of weeks to become a CNA, and the use LPNs for things the janitor can’t do. The registered nurse gets swamped with paper work and CYA work. checking drug profiles etc. and won’t even remember have of the patients in her care a week later. This is an insane system and we lose excellent nurses to it everyday.

  6. I agree with the above commenter. It would seem most logical to provide an easy pathway for LPN/LVN’s, given that they are aware of what the role truly entails and have experience in the working environment.

  7. This thread was started a while ago. I think a solution to some of the “nursing shortages” is to make it easier for LPN/LVN with a few years experience to enter into RN programs. I am a LPN with three years experience on a tele med/surge floor. I am having to wait with all the other students that have no experience for RN school, the lottery system wait list program they use typically runs three years. Even if I tried to get into the bridge programs, those spots are even more limited. The job is not for everyone, there aer lots that have some glorified view of what real nursing is, and that does not jive with reality which drives a lot of new nurses going into it for the money out. So, instead of spending the money educating people with no hands on experience before those that are about to lose their positions in the hospital because LPN/LVN’s are being phased out, give them priority. You wil find a well educated base to work with in their advancement to registered nurse status.

  8. I know these posts were a few months back… but if anyone is still reading them, i am a new grad in northern CA and I am making $41/hr to start. I do work nights so that is with an included &4/hr shift differential. However im working in a small hospital, not Kaiser or Sutter, and i will easily clear $80,000 my first year. Also i only work 3 nights a week doing 12 hour shifts, so like many of my friends have done, i have just applied for a per diem shift at Kaiser one 8 hour day a week and their per diem pay is $60/hr. Again, this is north of SF not a very big Kaiser Facility either. Graduated 2007 and have the potential to make over $100,000 in my first year with my ADN (not BSN). Harder to find jobs here because they pay, but thats the real deal! We also have nurse/pt ratios mandated by the state. As a med/surg nurse i have 5 max, though thats being pushed to change to 4 soon. telemetry is 1:4, ICU is 1:2….I have to chuckle to myself when i read these posts that there’s no way new grads can make $100,000 right out of school, because we’ve been doing it for a few years now. Job’s not easy, often i feel overloaded, fearful of giving safe care, and sometimes question if the money is worth it. Stressful day in and day out. But im doing it. Good Luck to all the nurses out there!

  9. Ummm, the reason CA and Manhatten nurses appear to make so much more money is not some powerful nurses’ association but cost of living. An apartment the size of a closet in the city can cost 2000 dollars a month to rent! In SC, where I live and work as a nurse, a 3000 square feet house costs less per month to own. So it may look like the nurses in those states are cashing in at 40 dollars an hour, but it’s equivalant to a nursing salary in SC that averages 25 dollars an hour. Nurses aren’t making the big bucks everyone thinks. We do alright.

  10. This is my first time writing on a blog. I am a foreign trained nurse, working in a emergency room in NY. My qualifications are similar to my co-workers. All foreign nurses must pass the State Boards before working in a hospital. I have been a nurse for many years now and it is definitely more stressful. Patients are sicker and are discharged home earlier than in previous years. The volume of patients seen in an ED on any given day has increased, yet the staffing remains the same. Nurses are required to know all the latest technology, medications, interpret abnormal labs and alert the physician,(who is also understaffed), when necessary. The patient is a more educated consumer, which is a good thing, but they also dictate to the physician and the nurse the testing and treatment that they would like to get. Regardless if it is appropriate or not.

  11. don’t worry y’all in the year 2010 i will be going to nursing school to get my RN license

  12. Just a followup. If you are curious about California nurse compensation, look at the California Nurses Association web site for the Kaiser contract:
    http://www.calnurses.org/facilities-bargaining/kaiser/
    Look at the top of page 6 of the contract summary, for hourly rates for Staff Nurse II.
    CNA has lots of other stuff on line; they obviously portray themselves in the best possible light, but they don’t fib.

  13. BettyJazz:
    ———-
    Whereas your point is well taken your salary range is a bit inflated and definately not entry as you claim. A more realistic range can be found on this website. http://www.allnursingschools.com/faqs/salaries.php
    I have been a nurse in NY for 30 years and never made that salary even in a management position.
    ———-
    In California, San Francisco Bay Area, $40/hr is starting base pay for new grad RNs at Kaiser; I got that number from a Kaiser recruiter September 27. (I’ll send you her email if you’d like, but I don’t have her permission to post it.) She also stated that after completion of their new grad training program, or 6 months of experience, the rate increases to $42/hour.
    CNA is a -very- effective union.
    Kaiser would not pay that if they didn’t have to – that’s the market rate. Kaiser and Sutter are the big players here, volume-wise. There are a few small private systems and some county hospitals; the latter do not pay quite so well. There are no openings on my county site for new grad nurses, so I can’t give you a number. A Charge Nurse, with 2 years+, gets $42 to $46 there.
    It’s true that California is not representative of the whole country.
    ———-
    Perhaps putting nursing back into hospitals instead of college classrooms could benifit both groups. One thought might be for experienced nurses to recieve an option for better hours and less workload to train students as part of her regular hospital duties.
    ———-
    I believe my preceptor got an extra $2 per hour last Fall when I worked in the hospital, for the shifts I worked with her. Didn’t change her assigned load any, though.

  14. Whereas your point is well taken your salary range is a bit inflated and definately not entry as you claim. A more realistic range can be found on this website. http://www.allnursingschools.com/faqs/salaries.php
    I have been a nurse in NY for 30 years and never made that salary even in a management position.
    As you reported nurses salaries are impressive. Hospital administrators find nurses salaries are one of the most expensive parts of a hospital budget. This is not just because of high salaries and benefits but because of the number of nurses needed to maintain the hospital. Nurses are needed to cover shifts 24×7 on every unit including clinics, doctors offices, emergency room, Home care, dialysis, surgery, discharge planning, and utilization review. There are even nurses involved in setting up computer programs/ nursing informatics, and of course in risk management and quality assurance. The hospitals won’t even get paid without nurses from the insurance companies authorizing payment.
    With so many nurses needed in every aspect of health care is there any wonder why paying so many salaries is difficult? What many hospitals and organizations are doing to ease the cost is to downsize. They will give various aspects of the nurses jobs to other less expensive staff such as nurse techs instead of nurses. They outsource by contracting with an external agency for nursing services they decrease cost for benefits and malpractice. Another ploy is to lay off nurses and rehire them back with a different title.
    Even if the schools could produce more nurses we are still faced with employers unwilling to pay for the experienced nurses needed to supervise inexperienced, per diem, or unlicensed personell or they are overwhelmed with mandatory overtime and on call workloads.
    All this additional responsibility burns out the experienced staff and puts patients at risk.
    Perhaps putting nursing back into hospitals instead of college classrooms could benifit both groups. One thought might be for experienced nurses to recieve an option for better hours and less workload to train students as part of her regular hospital duties. This would benifit the experienced nurses to prevent burn out and the hospital to have additional staff.

  15. Suvi–
    You ask: “Has it suddenly become more stressful? I don’t believe so.”
    Belief is one thing,fact another. Do some research (try Googling “hospital and errors and U.S.) and try http://www.healthaffairs.org and you will find that hospitals errors are up, and doctors and patients as well as nurses are complaining about how chaotic things are in many hospitals.
    As for shortening the amount of hands-on training that nurses have before throwing them into the pool–this is a recipe for disaster. Nursing is an incredibly difficult job that requires full professional training.
    We probably need more scholarships for nursing students, but not less training.

  16. Rob, Joe Blow, Sandy, John S., ER nurse
    Rob– What a terribly sad story. You are right. The market is not very good at setting long-term priorities. We need more nurses, not more lawyers. (See EMR nurse’s comment)
    This is why markets need some government oversight –from a government that is concerned about collective needs. As a very wise man once said: “We don’t just live in an economy; we live in a society.”
    Sandy– Clearly you know far more about the nursing profession than I do. And I would like to get more feedback from nurses about healthcare issues. They know a great deal about what is actually going on in our healthcare system, but are, understandably, often reluctant to talk. (Hospital politics–nurses are very vulnerable.)
    Sandy and Joe Blow: That said, John S. is right about salaries. My numbers were coming from California, and after seeing Sandy’s comment I did a little blogging. Nursing salaries vary widely by state and California is a state where salaries are much higher than in most. I suspect that this is because the California Nurses Association is a pretty powerful (and from what I know, good union/lobby.)
    Nursing salaries are also quite high in Manhattan;the two nurses I know work here.
    But I’m very interested in what Sandy has to say about nursing in other parts of the country. In particular, that “most experienced nurses are being laid off (and find it extremely difficult to find jobs) as hospitals favor young, inexperienced nurses they can pay less. And, more significantly, they are using foreign nurses and lesser-licensed and unlicensed personnel to provide patient care, at considerably lower salaries. Increasingly, fewer RNs want to remain in clinical practice as they are supervising large staffs of lesser qualified personnel, and their liability and workloads are too great to be fair to patients or worth the risk to their license.”
    I’d like to hear more about this.
    EMR Nurse: . . . I looked at your blog and liked it very much. Let’s talk– you can reach me at maggiemahar@yahoo.com. (Again, I’m looking for more input from nurses.)
    John S.– Thanks for clarifying where my salary numbers are coming from. I also would very much like to hear from you. (maggiemahar@yahoo.com)
    Thanks to all of you. This has been a a great thread– I hope others will join in and comment.

  17. Wages are so high because of stress? Not a persuasive argument! Has it suddenly become more stressful? I don’t believe so. High wages because supply is short? That’s more persuasive. There’s also the cost of housing in San Francisco. (I believe that in London they offer dormitory rooms to some nurses.)
    There’s also excess demand, inflated by tax laws, monopoly powers, and (in my opinion) some rather unthoughtful, indeed sentimental, policy makers and analysts.
    What is a free market solution to the nursing shortage? I notice that the online degrees are rather expensive. At least, from the point of view of the unemployed, or the second-career-seekers, $5000 a year is expensive. Perhaps something here could be automated, bringing the price of basic training to a level more conceivable to the poor, to provide a minimal pre-LPN degree in which only the last month would be the “hands on” training. The beginning nurse could then earn, and contribute, while learning more advanced skills.
    But this solution would require some flexibility on the part of the licensing boards.

  18. Sandy,
    Maggie’s example was California.
    The Cal State pay info is on line at
    http://www.calstate.edu/HRAdm/SalarySchedule/Salary.aspx
    Instructor is $50,580 up to 63,376.
    (tenure track)
    Asst prof is 60,828 up to 136,836.
    (tenured)
    Assoc Prof is 69,960 up to 150,312
    Full Prof is $88,524 up to 157,512
    Outside of California, I don’t know, but a PhD new-Assistant Professor will indeed make around $61K vs around $80K for a new-grad on the floor in the San Francisco Bay Area.
    I am myself a new-grad RN, and my wife is an instructor in the CSU system.

  19. You would think the Universities would respond to the need and produce more graduate level Nurses so Nursing programs could expand. In California, The University of California chose to produce more lawyers by opening up a totally unneeded new law school at UC Irving. While UC does have a few graduate level Nursing programs they are small by comparrison to the number of lawyers they produce and some funded by generous donations rather than being a UC priority. I spoke to that in one of my recent entries. http://ermurse.blogspot.com/2007/07/should-university-of-california-invest.html

  20. Joeblow:
    I’m calling BS on an entry level RN pulling down 100k. Nurses can top 100k if they have several years of experience in an ICU setting in SF/NY, but trust me no nurse is making 100k their first year on the job in a regular ward unit.
    ———-
    Maybe.
    Market for new grads (SF Bay area, large hospitals) is $40/hour base; after 6 months one is no longer a new grad, and the base rate is $42, so at 2,000 hours/year, that’s $82,000 Add shift differentials and weekends and I bet it’s close.
    Crossing the $100K boundary probably does require some high-demand specialty like NICU or ICU, and other circumstances.

  21. Thanks for all of your comments.
    Today I’m in Massachusetts speaking at the Massachusetts Medical Society conference (where people had some interesting things to say about nurses, the shortage of nurses and nurses’ wages.)
    When I get home this evening, I’ll reply to all of you.
    mm

  22. Yes, there is a nursing shortage, but I’m not buying this spin at all. As a BSN with 30 years experience, for many many years, it has been well-known in my region that salaries are intentionally kept down as a cost savings measure. In fact, the adage here is that the nursing shortage is largely self-induced. The most experienced nurses are being laid off (and find it extremely difficult to find jobs) as hospitals favor young, inexperienced nurses they can pay less. And, more significantly, they are using foreign nurses and lesser-licensed and unlicensed personnel to provide patient care, at considerably lower salaries. Increasingly, fewer RNs want to remain in clinical practice as they are supervising large staffs of lesser qualified personnel, and their liability and workloads are too great to be fair to patients or worth the risk to their license. This isn’t anything new, as nurses have been speaking out about this here since the 1980s. The PhD nurses at the University make comparable salaries to the nurses in clinical practice here; this article reads like it was written by PhDs looking for a pay raise.

  23. I’m calling BS on an entry level RN pulling down 100k. Nurses can top 100k if they have several years of experience in an ICU setting in SF/NY, but trust me no nurse is making 100k their first year on the job in a regular ward unit.
    the problem with nursing training is that nurses have decided that in order to teach nursing you have to have a PhD which is total bullshit. Up thru the early 1980s all the nursing instructors were bachelors or masters. It was only later that the nursing field decided they wanted to up the ante and require PhDs for all instructors.
    there’s absolutely no reason that a nursing instructor needs a PhD to teach nurses how to start IVs, change bedpans, administer meds, and do the other stuff that nurses do.

  24. Um. Yeah. But the “free” market isn’t addressing the problem of not having enough nurses, is it? It’s just making nurses more expensive (and rightly so, since professional wages are no longer $60,000, but twice that). So. Who’s really getting “market value?”
    I have a friend. She wants to go to nursing school. In our state, there are only a few universities. She applies. She is told there’s no room. Meanwhile, the local hospital is desperate for nurses.
    She decides to go on a different track, and work on a degree more applicable for laboratory research work while she tries to decide what to do. She’s told the chemistry class is full. All of them. In all the state. Full. Can’t even do remote access.
    So how’s the “market” going to work cooperatively on the collective problems of
    1) Not enough caregivers
    2) Not enough teacher
    ?
    Answer: By making the things we need to help those problems prohibitively expensive. Well done.
    Once again, this is about priorities. The real issues are manifold and complex. They reach deeply into the manufactured basis of our society.
    Ain’t gonna fix’em here. But the “market,” ladies and gents, isn’t “free.”

  25. Mark– You’re absolutely right–that is a typo. It should by “by 2020”–thanks for catching it.
    Chuck– You’re right in the sense that hte supply of nursing professors may well meet the number of spots available–becuase nuirsing schools lack the capital needed to expand. But given the number of qualified students who are turned away from nursing school (and he need for nurses), it seems pretty clear that we need more professors. And the way to attract them is to pay them at least as much as their students will make their first year out in the field.
    Brad–I agree, it could be a very rewarding career. This is one reason why so many students now want to become nurses. (In the past, wages were as low as the wages we pay public school teachers, for some of the same reasons. It was seen as a “woman’s job.” So this discouraged applicants (male and female)
    But finally, we realized that we needed to pay nurses professional salaries. I wonder what would happen (in terms of the applicant pool) if we began paying well-trained teachers (who had apprenticed as student teachers for a couple of years) $100,000 starting salaries??

  26. This is a great example of the free market at work. There’s a nursing shortage? Wages go up. The reason nursing professors don’t get paid well, is that we don’t have a shortage of professors.

  27. The statistic on nursing shortage seems to be a typo. The first figure is the shortage in 2005 of 218,000 nurses and then it estimates that in 2002 we will experience a shortage of 1 Million. (?)

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