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The Nursing Shortage That Isn't
In 1992, thirty years ago, my wife and I wrote a book called Modern Medicine: What You’re Dying to Know. Our subject was the causes of the high cost of health care. We had a chapter on each of the five factors we believed were contributing to skyrocketing healthcare costs: big business medicine, managed care, health insurance, malpractice—and the manufactured “nursing” shortage. This shortage appeared suddenly with the replacement of team nursing with primary care nursing. With the new role as primary care nurses, nurses became responsible for all care of their assigned patients and hospitals no longer had to employ aids, orderlies, and ward clerks.
“So while in 1968 only 33 percent of all hospital personnel were registered nurses, by 1986 that number had increased to 58 percent of all hospital personnel. And while the total number of registered nurses employed was increasing, the total number of full-time employees providing care to patients was decreasing radically. Hospitals employed 133,376 fewer full-time employees to provide patient care but increased registered nurse staffing by only 37,500 full-time positions (Mullinix, page 14). The nursing shortage, then, is an artificially created one.”
Modern Medicine: What You’re Dying to Know, p. 163
During medical school, I like many students, did a number of menial jobs to survive. In 1971 and 1972, I was what we called at that time an orderly and worked in a rehabilitation hospital. There were many quadriplegic and paraplegic patients in this facility. On my shift, which was 3 to 11, we had one RN and one LPN for 50 patients. We also had 7 or 8 aids and orderlies. I was paid 95 cents an hour. I worked hard. The nurses could do charting for 50 patients in about half an hour. Nobody complained of being overworked or short-staffed. If we were to apply our present nursing formula to that patient load of 50, rather than one RN being present, we would need 12. So, it is obvious where the shortfall is coming from. I’m not advocating that we return to one RN for 50 patients, but if we brought back the team approach to nursing, we could probably have 4 nurses instead of 12 taking care of those 50 patients.
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So yes, the nursing shortage was created with the introduction of primary care nursing, when the nursing hierarchy romanced the idea that the RN’s relationship to the patient would be so much better if the nurses started bringing in food trays, changing bedding, emptying bed pans, answering telephones and doing all sorts of other activities which had previously been done by less skilled personnel who were paid much less money. The total employee loss from 1968 to 1986 was significant and has remained a problem. I believe many nurses would actually like to see a return to team nursing. Many nurses understand the value and safety of the team care of patients.
What are we doing to prevent the mass exodus of experienced nurses from leaving their nursing careers?
In one of the hospitals I worked in, the nurses living in the community were very qualified, but they bypassed the local hospital and drove 50 to 80 miles to where they could work in a what they considered a safer environment. The nurses who left this hospital were replaced by locum nurses. Nurses who were provided no orientation by the hospital. One night I happened to be in the hospital about midnight for an emergency visit and while I was doing my charting, I heard a locums nurse who had been working in the hospital for about two years talking to a person on the telephone who wanted to come to the emergency room. She was telling the patient not to come to the emergency room. I asked her who she was talking to on the phone and she said, “I don’t know.” This was a problem on many levels and it could have made significant legal problems for the hospital, the nurse, and me, the physician because the patient should’ve been called back the next morning to see if they were feeling better and to see if they needed care. This nurse, besides not noting the name of the patient, also failed to get the patient’s phone number.
This kind of lack of care is not the fault of this nurse in particular. On the other hand, it is entirely reasonable to expect that an adult person with a three or four-year nursing degree should have enough common sense to figure out all by themselves that they needed to get the name, the phone number, make a note, and a return call. Several layers of hospital administration should have provided orientation to the locums nurse and trained her on what she should be doing with calls from patients.
Another problem is administrative nurses and hospital administration. Many advanced-degree nurses are hired by hospital administration to keep the nurses in line. I once had privileges at a hospital where the nurses all were forced to wear the same makeup, even similar hair styles. If they were told to work double shifts and refused, the Director of Nursing threatened to report them to the nursing licensing board for patient abandonment. Even in this environment, the nurses were constantly told how lucky they were to be working for such a fine hospital.
Nurses training has changed radically over the years. There’s been a push to have a four-year RN degree for the last 40 years. The old nurses trained years ago had a two-year RN degree or a three-year RN degree. My favorite nurses have always been those who had come from the three-year degree programs because in my experience, they have had the best judgment and the most skill.
I watched with interest some of the congressional hearing on the Patient Safety Act, House Bill 106 and Senate Bill 240. The act would require a ratio of 1 RN to 4 patients or less. I’ve watched the entire video of Ms. Aiken, PhD, FAAN, FRCN RN, the Director for the Center for Health Outcomes and Policy Research, addressing the House for Bill 106.
Dr. Akin was quit lacking in humility. Several times she noted that she had better research than anybody else. Despite her claiming she had the best research, she made a persuasive but rather empty presentation, talking about research but not discussing how the research applied to this push for changing the nursing ratio. She then went on to extrapolate, as in often done in research studies, about how many lives and much money would be saved and readmissions decreased. I saw no evidence that the legislators asked for any proof of anything.
As I’ve said before, the bad news is that the nursing shortage is manufactured, but the good news is that the solution is right under our noses. Making the problem worse by arbitrary ratios and more government belligerence is not going to fix the problem in this or even in the next decade. Fixing the artificially created nursing shortage by legislating nurse-to-patient ratios simply increases the cost of healthcare without fixing the misinformation that there is a nursing shortage.
“Aiken and Mullinix (1987) have studied hospital practices in hiring nurses relative to the perceived shortage. They observe that hospitals have increasingly utilized registered nurses while decreasing total hospital full-time equivalents. Indeed, the data shows that hospitals are not only substituting nurses for less skilled workers such as aides and licensed practical nurses, but also for workers with similar skills, such as respiratory therapy, physical therapy, and pharmacy. To hospital administrators, nurses, even at significantly higher salaries, are a bargain because they do the jobs of several employees. While this data certainly indicates that the demand for nurses has increased because of the way hospitals now would like to operate, there has been no study of the appropriateness of substituting nurses for other hospital personnel.”
Modern Medicine: What Your Dying to Know, p. 162
We had focus groups review Modern Medicine before we went to press. We had expected that the lawyers would be the ones most disturbed by what we said malpractice had done to healthcare. We were wrong. It was the nurses who were most angry about our assessment of what primary care nursing had done to drive up the cost of healthcare.
If we brought back the team approach to nursing and decreased the burden of charting, solutions to the artificially created nursing shortage would be available within the next 3 to 6 months. That’s practical. Government ratio edicts are not a solution to the problem. For real patient safety, we need plans that will bring about solutions in months rather than years or decades. Returning to the team nursing model could bring about significant reduction in the manufactured nursing shortage solution.
Aiken, L. A. and C.F. Mullinix. 1987. “The Nurse Shortage: Myth or Reality?” New England Journal of Medicine 317, 10, 641-646. [The same Aiken who now promotes nurse-patient ratios].
D.F. Mullinix. “Research on Influences Affecting Availability of Resources for Patient Care Delivery.” In proceedings of a conference of the National Institutes of Health, Bethesda, Maryland: U.S. Department of Health and Human Services, U.S. Public Health Service, National Institutes of Health, 1988, pp. 1-15.