Read an Excerpt
INTRODUCTION
News reports about the crisis in health care have become commonplace. In less than a decade, the face of the entire industry has changed. Numerous social and political forces—Reaganomics; an explosion in technological advances, epidemics in drug abuse, homelessness and communicable diseases, growing numbers of aging patients, and rising physician fees at odds with tightening insurance restrictions—arrived like overlapping waves, battering the system from within and without.
A major component of the health care crisis is the nationwide shortage of registered nurses. Headlines have described the shortage as “pervasive” and “epidemic,” its “dire effects” touching every aspect of health care. In December 1988, a federal panel appointed to investigate the problem by Otis Bo wen, then secretary of Health and Human Services, issued its first report characterizing the shortage as “of significant magnitude” and concluded that it was starting to “erode the quality of health care as well as access to services.” The most dramatic indications of the shortage have been reports of intensive care unit and emergency room closings, respective symbols of medicine’s most high-tech and essential services.
At the beginning of the 1990s, nationwide estimates of the number of vacancies for positions requiring a registered nurse range from 100,000 to 300,000 and are expected to double by the end of the decade. In January 1991, the American Journal of Nursing (AJN) reported that of 999 nursing homes surveyed by the American Nurses’ Association (ANA), nearly one-fifth of RN positions went unfilled. In its March ’91 issue, the AJN reported instances of staff shortages compromising care and endangering lives in a geriatric psych unit in Virginia and a Los Angeles neonatal intensive care unit. While there are more registered nurses today than ever before—their numbers rising past the two million mark in 1988—several trends, both in health care and the larger culture, have coalesced to create current conditions.
The Bowen Report panel had deduced that the nursing shortage was “primarily the result of an increase in demand, as opposed to a contraction in supply.” Increasing numbers of AIDS victims, drug-related hospital admissions, and the elderly have translated directly into a need for nurses. In March ’91, The New York Times reported that the elderly population is growing at a rate double that of the population in general. “Moreover, the elderly population itself is aging, with a larger proportion consisting of people over seventy-five years old, who require more care than those sixty-five to seventy- five.” In hospitals, where 70 percent of working nurses are employed, the explosion of technological developments has increased the need for highly skilled and knowledgeable personnel to manage the machinery that sustains life. That has translated into a need for more RNs, often by regulatory statute.
Probably the single-most significant event impacting upon health care in the United States in the last decade was the restructuring of the entire method of payment for services delivered to the public. Medicare prospective pricing for services—commonly referred to as DRGs (diagnostic-related groups)—originated as part of a broad legislative package with Congressional passage of the Social Security Amendments of 1983. This legislation was the result of years of effort to control skyrocketing health expenditures initiated in the 1960s with the creation of Medicare and Medicaid, which expanded health coverage to millions of previously unserved citizens.
In pre-DRG days, health providers were reimbursed retrospectively for each dollar spent on patient care. Under the new plan, Medicare—with other health insurers following suit—pays for services on the basis of pre-established “average” rates for diagnostic-related groups of illnesses. Put simply, DRGs mean that if a patient is admitted to a hospital for an ailment—which statistics show should, on average, require three days of care at a cost of $2,000—then that amount of money is given as a flat fee. The built-in incentive is to treat and discharge patients as quickly as possible because the dollar difference between the projected cost and the actual cost is retained and a profit made. However, if the patient is unable to be discharged in the average time, the hospital loses revenue.
A second major outgrowth of DRGs was the tightening of hospital-admission criteria, requiring more severe degrees of illness or impairment to gain entry, thus increasing the need for more intensive nursing care.
Initially, most health care analysts did not foresee how intimately DRGs and hospital nursing services would be bound together. In 1983, which saw the largest increase in nursing school enrollment in twenty years, there was a perceived RN market glut. Many hospital administrators, foreseeing potential financial shortfalls as a consequence of DRGs, cut back on nursing positions.
Over the eighteen months it took for that to evolve into a nursing shortage—when administrators finally realized that the impact of DRGs was to increase the patient acuity level (degree of illness) and therefore the demand for more nurses—those nurses had gone into other areas.
At the very time when more nurses were needed in hospitals, RNs were also being siphoned away by other modes of health care delivery. Nurses traditionally have worked outside hospitals in areas such as public health—visiting home nurses, school nurses—private industry, the armed services, and higher education. The past fifteen years have witnessed the emergence of other employment possibilities. HMOs, PHPs, freestanding clinics, “doc in the box” walk-in centers, and private-practice models frequently require the presence of RNs to attain licensure. There has also been a sharp increase in the numbers of nurses receiving master’s and doctoral degrees allowing them to move into more independent practice spheres. Nurses are also being enticed into other fields—pharmaceutical sales, computers, real estate, entrepreneurial endeavors—where their keen organizational skills are substantially rewarded.
Simultaneously, cultural directions developed that strike at the heart of the profession. At a time when women have far greater options in career selection—doctor, astronaut, Supreme Court justice—the “female profession” of nursing has fallen into disfavor. Its image as a passive, peripheral vocation, a “support” to the “important work” of physicians, holds little allure for women who wish to exercise mastery over their careers. There is a common perception that nurses are undercompensated for jobs requiring imposing physical labor and psychological stress. In 1987, for the first time, more incoming female college freshmen declared medicine over nursing as their intended major.
Anna, an adult family nurse practitioner with over fifteen years in practice, summed it up:
“I don’t know what is going to happen. They can’t keep nurses, and they’re not making as many as they used to. Women have other options in society, and they are exercising them. There’s more money to be made elsewhere. There’s more dignity to be had. There are more intellectually stimulating and less physically demanding jobs out there. There are places you can go to work looking good and smelling good, and come home the same way with more energy left over and more money to spend enjoying it.”
Against this tide, hospitals are scrambling to fill positions. Salaries have increased across the board. The October 1991 issue of RN Magazine reported a survey that touted nursing salaries as having risen 17 percent in two years, contrasted with an 11 percent hike in the cost of living. Numerous inducements are being employed to recruit new nurses and retain those with experience: sign-on bonuses of several thousand dollars, relocation allowances, subsidized housing, educational benefits expanded to include family members, bounties to staff nurses who recruit friends, and merit incentives. In 1990 a new hospital in the University of Texas system inaugurated a nine-month, schoolteacher-mode, work-year schedule for staff RNs.
Nursing recruiters travel around the country and as far away as Canada, Ireland, and the Philippines to lure nurses to better-paying, stateside employment. But not without problems. Fifteen percent of New York City’s RNs are foreign-nursing graduates. In 1988, a desperate Veterans Administration sparked controversy when it openly recruited nurses from Puerto Rico, waiving the requirement that they pass state nursing exams demanded of stateside nurses for licensure and calling into question the quality of care being afforded patients in VA hospitals.
Many observers view such “solutions” as makeshift measures, Band-Aids applied to a hemorrhage.
Within the work force, there are issues that predate Florence Nightingale but continue to cause resentment: interference from the dominant medical community, the amount and method of compensation for services, hospital administrations that give only lip service to the notion of nurses defining the parameters of their own practice. The desire to be accorded respect and authority commensurate with the responsibility carried by each nurse is keenly felt and continues to go largely unfulfilled.
Many seasoned RNs, having witnessed shortage scares before, scoff at hospital promos huckstering nursing care in the newly competitive health care environment: “Our nurses offer the personal touch. …” “When you reach out for someone in the middle of the night, our nurses are there.”
“It’s funny,” a Philadelphia nurse with eighteen years’ experience observed. “Nobody gave a damn about us until we started to disappear.”
