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Nursing Shortage Forces Hospitals to Cope Creatively
January 6, 2004
By LAURIE TARKAN
Banter in the hospital operating room may be less lively if
the surgeon's assistant is a robot rather than a nurse, but
that is of no concern to the inventor of Penelope. With a
six-year-old nursing shortage showing no signs of easing,
Dr. Michael R. Treat of the Columbia-Presbyterian Center in
Manhattan is hoping that his one-armed robot will replace
the nurse who hands the surgeon the instruments, freeing
the nurse to give postoperative care.
Other robots already ferry medications and supplies around
hospitals.
With mechanical help, flexible shifts and online auctions
of shifts, hospitals are surpassing the creative in dealing
with the nursing shortage that experts predict will worsen
in a decade or two.
The pressure on hospitals to attract and retain nurses
continues to grow, largely because of a mounting body of
evidence that being short staffed compounds the rate of
medical errors and deaths.
On Jan. 1, California became the first state to mandate
specific nurse-to-patient ratios. Hospitals there have been
scrambling to meet the deadline.
Around the country, using various strategies, some are
beginning to see their efforts succeed, leading to lower
vacancy rates in nursing jobs, lower turnover and lower
mortality rates for patients. In addition, hospitals are
seeing higher ratings of satisfaction among nurses and
greater satisfaction among patients.
In efforts to keep health care costs down in the 1980's and
early 90's, hospitals eliminated nursing positions and
tried to increase efficiency, but often at the expense of
nurses' working conditions, experts contend, decreasing
their flexibility, increasing their workload and reducing
their roles in decision making.
About 13 percent of nursing positions nationwide are
vacant, the American Hospital Association reports. Experts
predict that the rate will increase to 20 percent by 2015.
"Every hospital wants to hire more nurses and improve the
working conditions," said Amy Lee, spokeswoman for the
American Hospital Association, "but hospitals are in
fragile financial states, and some don't have financial
capital to do it."
The nursing shortage may have helped Charles Cullen, the
nurse who the police say has admitted killing 30 to 40
patients, to move from one hospital to the next in New
Jersey and Pennsylvania. The high turnover may have made
his short stays at many hospitals less conspicuous and led
hospitals to be less particular about their prospective
employees, said Dr. Linda Aiken, a professor at the
University of Pennsylvania School of Nursing, who is a
leading researcher on the shortage.
"High turnover rate," Dr. Aiken said, "is a very big
problem and potentially leads hospitals to be desperate to
try to get in sufficient numbers of nurses to keep their
services open."
Many hospitals have dealt with the shortage by requiring
overtime in understaffed wards. Nurses have complained that
management does not listen to their concerns, often
dismissing them with a take-it-or-leave-it attitude.
That relationship is not the only problem that has to be
noticed. A report just released by the Institute of
Medicine of the National Academies found that nurses'
working conditions were contributing significantly to
medical errors.
High patient-to-nurse ratios, fatigue on long shifts and
mandatory overtime, a lack of experienced staff, and
inadequate time to monitor patients have been associated
with poor medical results and higher death rates for
patients, the report said.
"Nurses can commit errors, and they also play a crucial
role in protecting patients from errors," said Dr. Donald
M. Steinwachs, who led the panel that issued the report.
According to a paper by the Joint Commission on the
Accreditation of Healthcare Organizations, low numbers for
nursing staffs was a factor in 19 percent of medical errors
resulting in deaths or serious injuries in hospitals.
Nurses' inadequate orientation and training were cited as
factors in 58 percent of serious errors.
A study by Dr. Aiken found that patients scheduled for
routine surgery were 31 percent more likely to die in a
hospital with a patient-to-nurse ratio of eight to one than
in a hospital with a ratio of four to one. The study was
published last year in The Journal of the American Medical
Association.
A majority of nurses say they believe that they cannot do
their jobs as well under their current working conditions,
a 2001 survey by the American Nurses Association shows.
The survey found that 75 percent of nurses said the quality
of nursing care at their medical centers had declined in
the prior two years. More than 40 percent said they would
not feel comfortable having a family member cared for in
their hospitals.
"I think hospitals could substantially improve nurses'
working conditions in ways that would have a very
significant impact on patient safety," said Dr. Steinwachs,
who is also chairman of the health policy and management
department at the Bloomberg School of Public Health at
Johns Hopkins.
The report recommended major changes in hospital culture.
Some hospitals have already started programs. To appeal to
young technologically oriented nurses, the Spartanburg
Regional Healthcare System in South Carolina began an
online auction that allows nurses to bid on extra shifts,
starting at $40 an hour. They bid down the wage by 50 cents
a bid; the lowest bidder wins the shift. On average, they
receive $38 an hour, which is $16 an hour more than their
typical pay.
Nurses gain flexibility and control over their schedules.
The hospital has decreased its reliance on agency nurses,
who cost more to employ and train than staff employees, to
4 from 54.
This month, the Cleveland Clinic Foundation began offering
a "mom shift" from 9 a.m. to 2 p.m. to attract nurses who
left the field.
"They can work while their kids are in school and be there
when they get home," said Claire M. Young, chief nursing
officer at the hospital.
The program has attracted 40 nurses.
The hospital also
offers a nine-month position with summers off, and it has
established a partnership with KinderCare Learning Centers
to offer child care. The hospital has lowered its nursing
vacancy rate to 6.2 percent from 12.8 percent in 2002.
Many hospitals have offered large sign-on bonuses and
improved benefits. Johns Hopkins Hospital in Baltimore
offers the benefit of paying 50 percent of college tuition
to any college for nurses' children. Other hospitals are
making special appeals to attract men, minorities and
foreign nurses. Hospitals have held health fairs in schools
to raise interest in nursing. One visited third graders in
a grammar school.
San Antonio Community Hospital in Upland, Calif., just
opened a concierge service to help nurses, who typically
have 12-hour shifts, to deal with daily errands. The
service offers laundry, dry cleaning, film developing, DVD
rentals, package and mail deliveries, and entertainment
tickets.
"This is a fairly low-cost way to add a benefit that makes
their lives easier," said George Kuykendall, president and
chief executive of the hospital.
Some hospitals have "lift teams" to help transfer patients.
About one-third of nurses suffer back-related injuries,
mostly because of lifting and transferring patients.
Some hospitals turn to robots. Along with the robot
Penelope, which has not yet been submitted for approval to
the Food and Drug Administration, nearly 100 hospitals have
used the Pyxis Helpmate, a robot that shuttles medication,
meals, lab specimens, supplies, medical records and
radiology films around the hospital. The robot is hard
working, at 24/7, and costs less than $5 an hour. It moves
at a slow pace and has to wait for the elevator like
everyone else. But it saves time by not chatting at the
water cooler.
Aside from such innovations, hospitals have begun to
address basic problems by ending mandatory overtime,
involving nurses in making decisions, listening to their
concerns and reducing paper and nonclinical work.
http://www.nytimes.com/2004/01/06/health/06NURS.html?ex=1074440866&ei=1&en=92f028f0892a5ca9
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