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Treating the Nurse Shortage

October 24, 2006
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Erin McKeon still fumes when she remembers her initial reaction last spring to an amendment to the U.S. Senate immigration bill and its solution for the U.S. nursing shortage.

    The amendment, proposed by Sen. Sam Brownback, R-Kansas, as part of the Comprehensive Immigration Re- form Bill, lifted the annual cap on visas for qualified foreign nurses. The amendment was overlooked by those who were focusing instead on such hot-button issues as border protection. But it certainly didn’t escape the notice of McKeon, associate director of government affairs for the American Nurses Association.

    "We completely opposed it," McKeon says of the nursing organization’s stand. "Immigration has been tried before as an answer to the nursing shortage and it has failed. We’ve gone down this path before and we don’t want to do it again. Cynicism tells me the reason Congress is looking at this is because it is cheap."

    The goal, she and others say, should be to generate a homegrown solution to the shortage, not to rely on foreign-born nurses as a quick fix for the problem.

    But those who favor lifting the visa cap for nurses—including the American Hospital Association—view it as a viable short-term remedy as more permanent strategies, such as increasing nursing school faculty, are gradually implemented.

    Both sides agree on one point: While the immigration bill is viewed by many as moribund, the nursing shortage is alive and well and won’t be fixed any time soon. It will only deepen, perhaps reaching a deficit of more than 1 million positions by 2020, according to estimates from the Health Resources and Services Administration.

    And the nursing shortage won’t just impact health care industry employers, experts warn. The lack of nurses could eventually affect all employers, either directly or indirectly, Mc-Keon and others say.

    "Waiting times in the emergency rooms are getting longer," says Beth Brooks, a senior partner at JWT Employment Communications, a global recruitment, marketing and internal communications agency specializing in health care. The nursing shortage is affecting or will affect ambulatory care, long-term care and doctors’ offices, she says. Sooner or later, nearly every employer will probably have workers affected by the shortage. "Nursing units are being closed," Brooks says. "In parts of the country, emergency rooms are going on diversion, sending patients to other hospitals. Elective procedures are being canceled or delayed indefinitely."

    While she isn’t aware of any study linking the shortage of nurses and its effect on health care with lower worker productivity or higher absenteeism, the potential for that effect is obvious.

    Currently, 118,000 registered nurses are needed to fill vacancies in U.S. hospitals, according to a report released by the American Hospital Association in April. Shortages at nursing homes also are significant, according to a survey of 6,000 facilities in 2002 by the American Health Care Association. It found 15 percent of staff RN positions were vacant, and that nearly 14,000 RNs would be needed to fill those vacancies.

    From 2004 to 2014, the U.S. health care system will need more than 1.2 million new nurses, according to a 2005 Bureau of Labor Statistics report. Recruiting new nurses was viewed as more difficult in 2004 than in 2003 by 40 percent of hospitals surveyed in an American Hospital Association 2005 workforce survey.

Causes of shortfall
    The shortage is fueled by a number of factors, including an aging nurse population, a shortage of faculty at nursing schools and a burgeoning population of baby boomers needing more health care, including skilled nursing services.

    "Some nurses are retiring earlier," McKeon notes, and applications to nursing schools began to drop in the early to mid-1990s. "At that time, hospitals were laying off nurses," she says, "and it was not seen as the best career choice. Other choices were becoming more open to women, such as medical school and veterinary school."

    The nursing workforce is aging, she says. "The average nurse today is 46.8 years old," McKeon says. Early retirement is understandable given the rigors of patient care, she says. "Nursing is a job that traditionally is very hard physically," she says. "It requires a lot of lifting and transferring of patients."


Sooner or later, nearly every
employer will probably have workers affected by the shortage. "Nursing
units are being closed. In parts of
the country, emergency rooms
are going on diversion, sending patients to other hospitals. Elective procedures are being canceled or delayed indefinitely."
--Beth Brooks,
JWT Employment Communications

    The shortage of nursing school faculty and facilities contributes to the problem, according to the American Association of Colleges of Nursing, which has 592 member schools. The association reported that U.S. nursing schools refused more than 41,000 qualified applicants from baccalaureate and graduate nursing programs in 2005 simply because of an inadequate number of faculty, lack of facility space or budget problems.

Solutions
    The nursing industry’s concern over raiding other countries for their nurses isn’t just self-protective, McKeon says. "We have great concerns over recruiters going overseas to recruit from communities who need them to come here and solve our shortage. Taking that one nurse from sub-Saharan Africa might take the only midwife out of the community."

    But Carla Luggiero, senior associate director of federal relations for the American Hospital Association, says that is seldom the case—that nurses are often recruited from countries with surpluses of nurses.

    JWT’s Brooks disagrees, saying some other countries don’t take kindly to U.S. raiding tactics. She went to a health policy conference recently attended by residents of several countries. "People were standing up and saying, ‘Please don’t take our nurses,’ " she says.

    "We believe America should be looking inward to solve our own nursing shortage," McKeon says.

    Luggiero agrees, but says it won’t happen quickly. "The fact of the matter is that would require a substantial expansion,’’ she says, referring to increased facilities and programs. "We would have to expand our domestic supply by making a considerable increase in our nursing school capacity, and that capacity is not there. There is a shortage of nursing school faculty. That has been well documented."

    The provision to lift the cap, she says, provides a way to ease the shortage while working on the long-term solutions. And, at least in the Brownback amendment, the eased restriction is meant to be temporary, ending in 2017. Currently, the U.S. allows 140,000 EB (employment-based) visas per year, and that includes five categories of workers, with nurses falling under EB3 visas.

    The issue of nurse shortages and other health care staff shortfalls is being studied by the federal Institute of Medicine. Meanwhile, some state initiatives are addressing the shortage of RNs. One in Pennsylvania created a half-dozen nursing education initiatives in March, encouraging current nurses to go back to school for graduate degrees and train the next generation. Maryland approved funding in January for the Nurse Support Program, providing competitive institutional grants to nursing schools in addition to new nursing faculty fellowships.

    Increasingly, nursing colleges and universities are forming partnerships to seek private support to solve the problem. Last year, Georgia Baptist College of Nursing formed a partnership with Piedmont Healthcare in Atlanta to recruit, educate and place more nurses in the system.

Curbing turnover
    Besides needing more educational facilities and teachers, the nursing profession needs an "upgrade" by employers, Brooks says. "The nursing work environment needs improvement," she says. "Some hospitals have a 20 to 30 percent turnover in the first year," she says.

    But some have impressively low turn-over, even 2 percent, she says. These hospitals would qualify for magnet status, so designated by the Commission on Magnet Recognition Program awarded by the American Nurses Credentialing Center, the national credentialing organization.

    About 200 of more than 4,900 hospitals in 42 states and one facility overseas have received magnet status for their exemplary practices, including Cedars-Sinai Medical Center in Los Angeles, UCLA Medical Center in Westwood, California, and Tampa General Hospital in Florida. Brooks says her company tells its clients, which include the University of Michigan Health Systems, Children’s Hospital of Atlanta and the UCLA center, that fostering a healthy work/life balance is just as important as recruiting good nurses.

    The magnet hospitals, the American Nurses Association’s McKeon says, "were the types of facilities that even during nursing shortages could keep their nurses. These facilities are demonstrating it is possible."

    Other hospitals could take a page from the magnet hospitals’ book, Mc-Keon says. "We believe that American health care facilities could be doing a lot more to maintain their nurses," she says. Among the policies that will quell turn-over, she says, include an end to mandatory overtime. A number of states, she says, have passed laws prohibiting that practice.

    "We limit the number of hours a pilot can work, but we don’t [always] put a limit on the number of hours a nurse can work," she says.

    Working conditions drive nurses into early retirement or a career switch, some say.

    And that number is not inconsequential, notes Rose Gonzalez, the ANA’s director of government affairs. In a letter sent in March to Sen. Arlen Specter, R-Pennsylvania, she notes that 17 percent of the current RN population in the U.S.—half a million nurses—have active licenses but no longer work in health care.

    Luggiero, for one, remains convinced that the problem needs both short- and long-term solutions. But the idea of a visa cap removal is not going to go away.

    "Well-educated, internationally educated nurses have been part of our health care industry for many, many years," Luggiero says. "They do provide a modicum of relief on the shortage front."

Workforce Management, October 9, 2006, p. 1, 39-42 -- Subscribe Now!

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