Not so long ago, the air was filled with dire warnings of an impending nursing shortage. By 2020, according to one widely-cited analysis, demand might exceed supply by as many as 800,000 nurses.
That analysis was made in good faith, and it was based on not-crazy extrapolations from thirty years’ worth of economic data.
But in many local labor markets in 2012, there’s no sign of a shortage. In fact, in some regions there’s evidence of a glut. A few months ago, the California Institute for Nursing & Health Care announced that 43 percent of people who received nursing degrees in California and 2010 and 2011 were not working as nurses.
I’m going to try to make some dimly-informed comments about the nursing labor market in the next few posts. But first, a few words about what it means to say that there is (or isn’t) a nursing shortage.
In this context, “nursing shortage” is used in an unsentimental labor-economics sense. A nursing shortage exists when employers are actively trying to hire additional nurses but are rubbing against supply constraints, as evidenced by:
rapidly rising wages
heavy use of temporary “agency” nurses to fill gaps on units
a greater-than-usual willingness to hire nurses with little experience or limited training
new investments in nurse-replacing technology
desperate 3 am phone calls from hospital administrators to college presidents, begging them to launch new nursing programs
To say that there is no nursing shortage today is not to say that all hospital units are adequately staffed for patient safety and decent quality of care. There is plenty of reason to believe that patients would be better off if hospitals invested in stronger nurse-patient ratios.
There are lots of losers in President Obama’s effort to remake the U.S. health care system, and chief among them are the doctors. But there are also winners, especially nurses and physician assistants (PAs). Indeed, nurses and PAs win big in part because doctors lose badly.
Surveys repeatedly show doctors are fed up with low reimbursement rates from Medicare and even lower from Medicaid, which have increasingly led doctors to no longer see new patients in those government-run plans. For example, a recent Texas Medical Association survey found that “34 percent of Texas doctors either limit the number of Medicare patients they accept or don’t accept any new Medicare patients.” Even more do not accept patients with Medicaid.
Then there’s the heavy-handed regulations and requirements from both government and private health insurers. Complying with all those requirements and paperwork creates expensive and time-consuming administrative burdens. And to top it off, there’s the looming shadow of a high-cost lawsuit if things don’t turn out well.
And that’s all before ObamaCare kicks in, which will exacerbate every one of those problems. So it’s little wonder that there are physician shortages, especially in lower-paying primary care, and those shortages are only going to get worse if ObamaCare succeeds in getting an estimated 32 million more Americans insured.
The increased demand for medical care and lower reimbursements—which is one of the primary ways ObamaCare will try to hold down costs—is a recipe for a mass exodus of doctors willing to practice medicine. As “Physicians Practice” reported in August from its physician survey: “Nineteen percent say they plan to move to another position in the same field. An equal amount says they plan to leave medicine—not to retire, but to pursue something new.”
This month’s wretched jobs report tells a now-familiar tale: Employment has risen nicely in health care (a net gain of more than 340,000 jobs between May 2011 and May 2012). But almost every other sector has been flat or worse.
You might think that would mean that new-graduate nurses are having an easy time finding work. That’s still true in rural areas — but elsewhere, no.
In many U.S. cities, especially on the west coast, there’s real evidence of a nursing glut. The most recent survey conducted by the National Student Nurses’ Association found that more than 30 percent of recent graduates had failed to find jobs.
How is that possible?
While demand for nurses has been rising, it actually hasn’t risen as fast as most scholars had projected. Meanwhile, the supply of nurses has spiked unexpectedly, at both ends of the age scale: Older nurses have delayed retirement, often because the recession has thrown their spouses out of work. And people in their early twenties are earning nursing degrees at a rate not seen in decades. We’re now in the sixth year in which health-care employment has far outshone every other sector, and college students have read those tea leaves.
How many times have you read about the staggering shortage of nurses? It’s routine to see numbers in the hundreds of thousands tossed around – representing the seemingly insatiable demand for nurses from an aging population. I’ve always been suspicious of these estimates. First, it’s not how the economy works. We’re not really going to have 260,000 unfilled nursing positions in 2025. Either supply will rise, demand will fall or there will be a substitution of other kinds of labor or capital. Second, these numbers often come from interested parties, usually advocates for higher nurse pay and benefit or people who are running nursing schools and would like them to expand.
So I was struck by an article today that mentioned a glut of nurses, even in places like California that mandate minimum nurse staffing ratios. The situation is blamed on the recession, which depresses demand as hospitals and other nurse employers seek to control budgets, and also increases supply as nurses delay retirement, seek more hours, or return to work when a spouse is laid off. I’m sure there’a lot of truth to this, but if there is really such a big shortage it shouldn’t turn into a glut so quickly.
I don’t think employers of nurses are quaking in their boots due to the prospect of a gaping shortage of nurses. Although they might not say so openly (since everyone loves nurses) the forward thinking hospitals are planning for the day when nurses comprise a substantially smaller portion of their costs than they do now. They’ll do it with better decision support systems, workflow tools and robots that will take over many routine and high-skill nursing functions. Hospitals may seem capital intensive now, but I really believe there will be even more substitution of capital for labor in the future.
So if you’re betting on a giant nursing shortage in the year 2025 my guess is you’re going to lose.
The legislation, co-led by Rep. Peter King (NY-3), would elevate the existing Chief Nurse Officer of the US Public Health Service, to the National Nurse for Public Health, a new full time leadership position that can focus nationally on health promotion and disease prevention priorities.
Teri Mills, a Certified Nurse Educator at Portland Community College in Oregon and President of the National Nursing Network Organization (NNNO), introduced the idea of a National Nurse in a 2005 NY Times op/ed. Here is an excerpt from that article.
…Nurses are considered the most honest and ethical professionals, according to a recent Gallup poll. It’s the nurse whom the patient trusts to explain the treatment ordered by a doctor. It is the nurse who teaches new parents how to care for their newborn. It is the nurse who explains to the family how to comfort a dying loved one.
Now, I’m not saying that a National Nurse will become a household name immediately. But given all that’s at stake – the health of a nation – it seems to me that we should at least give nurses a try.
After Hurricane Katrina hit New Orleans, several hundred thousand refugees descended on Dallas, Houston and other Texas cities. Many of them needed medical care. Unfortunately, Texas wasn’t prepared.
If a natural disaster hit Oregon, the victims would have fared much better. The state’s 8,500 nurse practitioners (NPs) are free to come to the aid of people in need of care, with no legal obstruction. In Oregon, nurses with the proper credentials and licensure may open their practices anywhere they choose and operate in the same capacity as a primary care physician without oversight from any other medical professionals. They can draw blood, prescribe medications, and even admit patients to the hospital.
In Texas, which has some of the most stringent regulations in the country, however, a nurse practitioner can’t do much of anything without being supervised by a doctor who must:
Not oversee more than four nurses at one time.
Not oversee nurses located outside of a 75 mile radius.
Conduct a random review of 10 percent of the nurses’ patient charts every 10 days.
Be on the premises 20 percent of the time.
Note that under the rubric of “nurse,” there are a host of subcategories. In general, nurse practitioners have the skills to prescribe, treat and do most things a primary care physician can do. They generally must have completed a Registered Nurse and a Nurse Practitioner Program and have a Masters or PhD degree. In addition, there are physician assistants, registered nurses, licensed vocational nurses, emergency medical technicians, paramedics and army medics. In most states, each of these categories has its own set of restrictions and regulations, delineating what the practitioners can and can’t do.
All of us have been to fast food establishments. We go there because we are in a hurry and it’s cheap. We love the convenience. We expect that the quality of the cuisine will be several rungs lower than fine dining.
We now have a fast medicine option available to us. Across the country, there are over 1000 ‘minute-clinics’ that are being set up in pharmacies, supermarkets and other retail store chains. These clinics are staffed by nurse practitioners who have prescribing authority, under the loose oversight of a physician who is likely off sight. These nurses will see patients with simple medical issues and will adhere to strict guidelines so they will not treat beyond their medical knowledge. For example, if a man comes in clutching his chest and gasping, the nurse will know not to just give him some Rolaids and wish him well. At least, that’s the plan.
Primary care physicians are concerned over the metastases of ‘minute-clinics’ nationwide. Of course, they argue from a patient safety standpoint, but there are powerful parochial issues worrying physicians. They are losing business. They have a point that patients should be rightly concerned about medical errors and missed diagnoses at these medical care drive-ins. These nurses, even with their advanced training, are not doctors. It is also true serious or even life threatening conditions can masquerade as innocent medical complaints and might not be recognized by a nurse who treats colds and ankle sprains.
The sad case of Kimberly Hiatt, a Seattle nurse who committed suicide months after being disciplined for administering a fatal dose to an infant, is starting to make the rounds. Josephine Ensign, for example, concludes her blog post on this by saying:
I am left with many questions. Why was the nurse treated so differently from the dentist or physician at the same hospital for similarly serious medication errors? If one in three hospital patients in the US experiences serious preventable adverse events and we know that it’s “the system, stupid,” why are most of our efforts put into educating patients to advocate for safer care? If nurses are simultaneously being told by hospital administrators to report errors and then facing serious retribution for making honest unintentional mistakes . . . what do I teach my students to do?
We can never know, of course, whether the suicide was related to the incident itself, the disciplinary action, or indeed, some other aspect of Hiatt’s life. But the sequence of events will cause many to draw the connection between the way Hiatt was treated after the accident and her death. In any event, though, the ambiguity as to whether or not it was connected does not take away from the kinds of questions raised by Ensign.Continue reading…
How many nurses does it take to care for a hospitalized patient? No, that’s not a bad version of a light bulb joke; it’s a serious question, with thousands of lives and billions of dollars resting on the answer. Several studies (such as here and here) published over the last decade have shown that having more nurses per patient is associated with fewer complications and lower mortality. It makes sense.
Yet these studies have been criticized on several grounds. First, they examined staffing levels for hospitals as a whole, not at the level of individual units. Secondly, they compared well-staffed hospitals against poorly staffed ones, raising the possibility that staffing levels were a mere marker for other aspects of quality such as leadership commitment or funding. Finally, they based their findings on average patient load, failing to take into account patient turnover.
Last week’s NEJM contains the best study to date on this crucial issue. It examined nearly 200,000 admissions to 43 units in a “high quality hospital.” While the authors don’t name the hospital, they do tell us that the institution is a US News top rated medical center, has achieved nursing “Magnet” status, and, during the study period, had a mortality rate nearly 40 percent below that predicted for its case-mix. In other words, it was no laggard.
As one could guess from its pedigree and outcomes, the hospital’s approach to nurse staffing was not stingy. Of 176,000 nursing shifts during the study period, only 16 percent were significantly below the established target (the targets are presumably based on patient volume and acuity, but are not well described in the paper). The authors found that patients who experienced a single understaffed shift had a 2 percent higher mortality rate than ones who didn’t. Each additional understaffed shift carried a similar, and additive, risk. This means that the one-in-three patients who experienced three such shifts during their hospital stay had a 6 percent higher mortality than the few patients who didn’t experience any. If the FDA discovered that a new medication was associated with a 2 percent excess mortality rate, you can bet that the agency would withdraw it from the market faster than you could say “Sidney Wolfe.”
The effects of high patient turnover were even more striking. Exposure to a shift with unusually high turnover (7 percent of all shifts met this definition) was associated with a 4 percent increased odds of death. Apparently, patient turnover – admissions, discharges, and transfers – is to hospital units and nurses as takeoffs and landings are to airplanes and flight crews: a single 5-hour flight (one takeoff/landing) is far less stressful, and much safer, than five hour-long flights (5 takeoffs/landings).Continue reading…
If you have been at your nursing job for a while, you’ve probably almost forgotten.
Forgotten what it was like to come in to the healthcare system you now work for and realize there are hundreds of new protocols for you to learn and adhere by as a nurse. After years of routine, you now go about your day as if you actually have some choice in the way you give care.
At one point you probably did. I was not around during this age of nursing. The age when we had autonomy. Freedom to practice. Freedom to be innovative.
Today, I am somewhat saddened by the current state of the nursing profession. Don’t get me wrong: I LOVE what I do. I am so thankful for the opportunities set before me.
But whatever happened to “nursing judgment”? Or “nursing decision”?
I can’t tell you how much recently I’ve heard the phrase, “It is hospital policy that…” “You can’t do that, it is protocol that…”
I understand the need for protocols. They help us in the case that something goes wrong and the hospital gets sued. Did the nurse adhere to the protocol? If not, they will be subject to disciplinary action and take the fall. If something goes wrong and there is no protocol, the hospital can say in its defense: “There is now a protocol in place.”
Maybe a less cynical need for protocols: promote and regulate evidenced-based practice among nurses. Evidenced-based practice was developed for a reason: it brings good outcomes and protects the patients.
Even so, to me it seems we are being protocoled to extinction.