Staffing models: Nurse shortage spurs hunt for perfect ratios

State legislatures codify numbers

From protests in Massachusetts to legislation in California, from federal measures in Washing-ton, DC, to sign-on bonuses in Texas, the nurse staffing shortage has made the big time and grabbed the uneasy attention of health care administrators, lawmakers, and nursing professionals nationwide.

The federal Bureau of Labor Statistics projects that during the next six years, the need for RNs will grow by 21%, while the growth for all occupations will be 14%. Demand is expected to exceed supply by 2010, and statistics suggest that by 2015, the deficit will reach 114,000 full-time RN positions. In other words, left to its own devices, the nursing shortage is going to get worse, not better.

Some key factors at work:

• About half the RN work force will reach retirement in the next 15 years.

• The average age of new RN graduates is 31; they are entering the profession at an older age and will have fewer years to work than nurses have had traditionally.

• RN enrollment in schools of nursing is down. Entry-level BSN enrollment has fallen 6.6% from a year ago, dropping for the third year in a row, according to the Washington, DC-based American Association of Colleges of Nursing.

• Modifications in managed care and a new push for competitive quality are increasing acuity in many units, as well as patient days, hours of nursing care, and the recognition of the role of the RN.

But the industry need not wait 15 years to see fallout from all those factors. Problems are starting to show up now. Mary Lee Mohr, director of nurse recruitment at University Hospital in Denver, has been wrestling with staffing shortages since she started her job there three years ago, and she points out how frustrating the economics of the situation can be. "I use outside agencies," she says, "but it costs a lot of money. We float nurses when we can, and if we simply can’t staff the unit then we hold beds. That means sending patients to other hospitals, which also costs money."

Because of the proliferation of managed care and the subsequent reduction of professional staff, consumers are showing concern about the quality of care available in hospitals, and state legislatures are taking action. In 1998, staffing bills were introduced in 24 states. In 1999, bills were brought to the legislatures of 15 states. Bills that have passed include:

• Kentucky’s new law that mandates all licensed facilities to provide an appropriate mix of licensed and unlicensed personnel;

• a New Mexico appropriation of $150,000 to fund a nursing work force study;

• a law in New Hampshire that requires hospitals to report a number of variables, including rates of RNs per bed, to a newly established Health Care Quality Commission.

California recently became the first state in the nation to pass and sign into law a measure requiring minimum ratios of nurses to patients in all acute hospital and psychiatric hospital units. (See box, p. 16.) The bill does not use actual numbers, since the needs of any particular unit varies from day to day, even hour to hour.

Beverly Malone, RN, PhD, FAAN, president of the American Nurses Association in Washington, DC, objects strongly to the idea of prescribed numbers for nurse-to-patient ratios. "The idea that a nurse is a nurse is a nurse’ — that one can just count nurse bodies and patient bodies and state the ratio between them — just doesn’t hold," she insists. "Clinical knowledge, knowledge of the unit, and getting enough downtime between shifts also influence the quality of care."

So does the availability of skilled aides who can help cut down on the nursing staff responsibilities for cleanup, paperwork, and other nonclinical duties.

"Staffing decisions should be based on real patient conditions and real provider competencies," adds Malone, "not on a cookie-cutter approach that treats patients and their nurses as widgets on an assembly line." (See decision-making matrix, below.)

Late last year, nurses at St. Vincent Hospital in Worcester, MA, demonstrated to protest a situation in which one nurse was caring for nine critically ill patients on a single shift. Other hospitals in Massachusetts have been the object of nursing strikes and protests related to dissatisfaction with staffing levels. It’s a widespread problem that also affects much of Europe, Australia, and the Philippines. In the United States, it stems from combined issues that include steep population growth in some states, a diminishing supply of new nurses, an aging work force, and a baby boom bubble that will require intense health care services just as the majority of nurses are retiring.

So, what are the solutions? "The big thing for us right now is retention," says Mohr. And she notes that a lot of the motivation for a nurse to stay on comes from the top down. "Money isn’t the issue. A veteran nurse can earn more than $23 an hour for a straight shift and more for overtime and weekends. The big thing is work satisfaction. Our management incentives include turnover levels, and I have some great directors here who make a big difference in our retention efforts."

Laura Mahlmeister, RN, PhD, president of Mahlmeister & Associates, a California nursing consulting firm, agrees that the attitude of management is the biggest factor in nurse retention. "These nurses need to be treated like professionals," she insists. "Don’t send nurses home without pay on down days. That reduces them to nothing more than clock punchers. There are alternatives for them when the census is down. They can go to the management pool and work on policies and procedures. They can go to a continuing education program for the day if one is available. If there is no viable option and they must be sent home, then send them home with pay or with comp time. But show that you value them as professionals."

University Hospital maintains strict staffing minimums. "There are never fewer than two RNs on a unit," Mohr explains, "and we seldom use LPNs because of the restrictions on their licenses." Does this mean nurses are asked to do more than should be expected? "I don’t think they’re asked to do more clinically," she says, "but they’re certainly asked to work longer hours."

University Hospital also fills in with Canadian nurses for whom Mohr can arrange six-month work permits. "The permit maximum was recently expanded to a year, and now the demand is such that we’re hearing it could be extended to two years," she says.

The need for additional nurses in certain areas is so critical that President Clinton recently signed a bill to provide up to 500 non-immigrant temporary visas per year to foreign nurses to help alleviate shortages for hospitals in the most affected areas, usually in rural or inner-city areas. The legislation is sensitive to the needs of domestic nurses, protecting their salaries and positions and limiting the number of foreign nurses per facility.

In the meantime, hospitals are working with various incentives to recruit and retain their RNs. For example, hospitals in Texas, Virginia, and New York have instituted sign-on bonuses of up to $5,000. "In California, I’ve seen bonuses as high as $7,000," says Mahlmeister.

One important need that Mohr sees for many RNs is flexibility. They want family time, personal time, perhaps part-time work, and just plain breathing time. "Float pools are a big help," Mahlmeister says. "If recruitment and staffing offices can find enthusiastic float nurses, particularly in highly skilled areas like critical care and labor and delivery, it gives the float nurses the flexibility they need and the shift nurses the added RN support they may be missing."

Ensuring a strong work force

But some solutions that have been developed in response to the nursing shortage are opposed in a joint position statement from the American Nurses Association, The National Federation of Licensed Practical Nurses, and the National Council of State Boards of Nursing. The statement warns against solutions that are "expedient, inefficient, . . . and lead to unsafe delivery of nursing care," including:

• delivery of nursing care by non-nursing personnel not under the supervision of a licensed nurse;

• substitution of licensed nurses with unlicensed personnel;

• unnecessary creation of new categories of health care personnel . . . [which] serves to fragment care;

• lowering of established legal standards [for] . . . the licensure of persons who have not demonstrated competence to practice nursing;

• lowering of professional nursing standards.

Hospitals already face competition for qualified nurses from managed care, pharmaceutical, and nonhealth-related companies, according to a survey done last year for the American Organization of Nurse Executives (AONE) in Chicago.

With enrollment in four-year nursing programs dropping and the average age of nurses now at 44, hospital leaders must scramble to recruit qualified RNs. The AONE survey shows that flexible hours was the incentive most commonly used. Bonuses and child care also were noted.

But the larger question is: What can health care administrators do to ensure a strong work force in the years to come? Sigma Theta Tau, the International Honor Society of Nursing, based in Indianapolis, has a number of recommendations:

• Reposition nursing as a highly versatile profession in which young people can learn science and technology, customer service, critical thinking, and decision making.

• Construct practice environments that are interdisciplinary and build on relationships between nurses, physicians, other health care professionals, patients, and communities.

• Create patient care models that encourage professional nurse autonomy and clinical decision making.

• Develop additional evaluation systems that measure the relationship of timely nursing interventions to patient outcomes.

• Develop career enhancement incentives for nurses to pursue professional practice.

The bottom line: It appears that administrators must learn to understand what patients require for adequate professional care; what nurses want in the way of professional incentives, leadership, and assistance in their workplace; and what makes nurses love their jobs. Then they must address those issues on a consistent and generous basis. That seems to be the message nurses are sending, and the most realistic way to avoid what could be a potentially major health care crisis, boost the image of nursing across the board, and stimulate enrollment in schools of nursing.

Matrix for Staffing Decision Making
Items Elements/Definitions
Patients Patient characteristics and number of patients for whom care is provided
Intensity of unit and care Individual patient intensity; across the unit intensity (taking into account the heterogeneity of settings); variability of care; admissions
Context Architecture — geographic dispersion of patients; size and layout of patient rooms; arrangement of entire patient care unit(s); technology (beepers, cellular phones, computers); same unit or cluster of patients
Expertise Learning curve for individuals and groups of nurses; staff consistency, continuity, and cohesion; cross-training; control of practice; involvement in quality improvement activities; professional expectations; preparation and experience
Source: American Nurses Association, Washington, DC.

[For more information, contact:

• American Nurses Association at (202) 651-7000.

• Mahlmeister & Associates at (415) 564-6490.

• Sigma Theta Tau International Honor Society of Nursing, Andrea McDonald at (888) 634-7575.]