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Beyond Safety and the Nursing Shortage: A Threat to the Heart of Nursing
Several months ago, at a social gathering of community leaders, an older gentleman was decrying the fact that so many nurses have become real estate agents. These agents, he said, were very efficient, hard working, and knowledgeable. Why would a nurse ever leave all that experience and education to sell houses?
Since then, the Journal of the American Medical Association (JAMA) has released a widely publicized study revealing the quantifiable and adverse outcomes associated with certain patient-to-RN ratios. How does this affect a nurse's perception of patient care delivery or the obligation to provide safe, reasonable care? Equally important, to what extent has the spirit of nursing been undermined based on this seemingly dismal situation? Healthcare professionals by nature tend to have the patient's best interest at heart, but proponents of the theory compassion burnout might argue that these circumstances are damaging the essence of the caring professions.
Current State of the Shortage
The current nursing shortage is a local, regional, national, and global concern. Experienced RNs are needed in all areas. Unlike previous crises, traditional recruiting efforts are not proving successful. This may be due to the rapidly changing demographics of the American population. For example, people older than 85 are the fastest growing segment. Baby boomers are close to retiring. Not only are nurses necessary to care for this aging sector, but also they are aging along with the rest of the population. The average RN is 44 years old and one-third of the RN population is over 50.1
The Bureau of Labor Statistics projects a 12.5% increase in hospital-based nursing positions by 2005, and yet colleges have not expanded nursing programs because they are more expensive to provide than other educational programs. Even universities and colleges offering nursing programs have discovered that many young men and women are not choosing nursing as a profession. At the same time, nurses are discovering more work options within and beyond healthcare. Hospitals and colleges face intense competition. Numerous barriers exist in addressing this shortage.
What are the Barriers?
Barriers to resolving the current shortage are attributed to the aging nursing workforce, low unemployment, and the global nature of the shortage. Additionally, some authors believe that the increased level of patient acuity leads to challenges in recruiting experienced or especially skilled RNs.2
National trends in the general work environment are different now than during the last nursing shortage. Employees today seek more personal time as opposed to financial compensation. Employees want to be active both at work and at home and don't want to choose between the two. Employees in their 20s and 30s view the workplace differently, preferring greater autonomy and less bureaucracy. They are loyal to work rather than the employer. Thus, many are choosing independent work, consulting opportunities, or temporary work through agencies. Each of these factors, coupled with the traditional and hierarchical nature of hospital structure, discourages long-time hospital nursing employment. These circumstances work together to create a nursing shortage that serves as a threat to patient safety.
The Danger
A recent of study 168 hospitals in Pennsylvania suggests that for each additional patient more than four in a registered nurse's workload, the risk of death increases 7% for surgical patients. Patients in hospitals with the lowest nurse staffing ratios (eight patients per nurse) have a 31% greater risk of dying than hospitals with four patients per nurse.3 On a national scale, staffing differences of this magnitude could result in as many as 20,000 unnecessary deaths annually. Issues surrounding the current shortage are complex, and barriers further stymie the resolution of these issues. Researchers predict that the current nursing shortage is more serious and will last longer than those previously experienced. Strategies used in the past will provide limited relief in the current shortage.2 This persistent lack of human resources is likely to further lead to nurse burnout.
The Threat to Nursing
Higher emotional exhaustion and greater job dissatisfaction in nurses were strongly and significantly associated with patient-to-RN ratios. Research suggests that 43% of nurses who reported burnout and were dissatisfied with their jobs intended to leave their current positions within the next 12 months.3
This is costly emotionally and economically.4 Economically, reports suggest the cost of training a new nurse is between $42,000 and 64,000.4 Emotionally, many experienced RNs are finding less satisfaction in their work and leaving the healthcare workplace.
Ethical Considerations
One might argue that an obligation exists to protect the vulnerable segments of society. However, identifying and protecting the vulnerable parties prompts additional debate. Taxpayers are vulnerable economically; funding is finite. Nurses are vulnerable emotionally and physically, and additional workloads are thought to contribute to caregiver injury. How does an idealistic, inexperienced, enthusiastic nurse become a realistic but hardened, experienced yet dispirited nurse, and how can this be prevented? The answers to these questions may provide the solution to the current and subsequent nursing shortages with regard to both recruitment and retention.
Consumers are vulnerable because having fewer nurses poses an actual or perceived threat to care. Plus, nurses are thought to speak for the underserved, a consideration mandated by state nurse practice acts.
To what extent do consumers, healthcare professionals, organizations, and policy makers have an obligation to protect the essence of healthcare and healthcare professionals? Is healthcare a special and therefore protected profession?
Stakeholders are seeking solutions to the current situation. Ideas have been posed and debated in professional journals, newspaper commentaries, and television talk shows. Regardless of the outcome of the shortage, as healthcare professionals, our interests and the interests of our patients are best served by considering the emotional impact this situation creates among caregivers.
1. Shusterman C. Fact Sheet on the Hospital Nursing Shortage. Available at: http://www.shusterman.com/rn-facts.html. Accessed October 30, 2002.
2. Nevidjon B, Erickson JI. The nursing shortage: solutions for the short and long term. Online Journal of Issues in Nursing. 2001;6(1) manuscript #4: Available at: http://www.nursingworld.org/ojin/topic14/tpc14_.htm.
3. Aiken LH, Clarke S, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout and job satisfaction. JAMA. 2002;288(16):1987-1993.
4. Nursing Executive Committee. Reversing the flight of talent: nursing retention in an era of gathering shortage. Washington, DC: Advisory Board Co. 2000. Additional Resources on the Nursing Shortage Call for Action to Solve America's Nursing Shortage. Joint Commission Teleconference Transcripts. Access at: http://www/jcahco.org/news+room/press+kits/nursing+transcript.htm.
