Providers try more education, better team concepts
In August 2002, the Roosevelt Warm Springs (GA) Institute for Rehabilitation found itself with 44% of its registered nurse (RN) positions vacant. The facility’s licensed practical nurse (LPN) vacancy rate was 30%.
Those numbers are high enough to make any rehab administrator shudder. "We were in critical mode," says institute spokesman Martin Harmon. "We put together an interdisciplinary committee to work on the problem, and things have stabilized. It’s still a problem, but we’ve leveled the playing field some."
The institute now has a vacancy rate of 13% for RNs and 10% for LPNs. Harmon credits the improvement to a salary increase, internships with regional nursing schools, and an increased presence from nursing staff and human resources staff at job fairs. The institute also has encouraged nurses’ autonomy and input through an enhanced team concept.
Nursing shortage expected to intensify
Experts expect the nursing shortage experienced at Roosevelt Warm Springs and other hospitals across the country to intensify as baby boomers age and the need for health care continues to grow. The Health Resources and Services Administration estimated in a July 2002 report that 30 states had RN shortages in 2000 and as many as 44 states will have a shortage by 2020 (see the report at http://bhpr.hrsa.gov/healthworkforce). The U.S. Bureau of Labor Statistics projects a 21% increase in the need for nurses nationwide from 1998 to 2008, compared with a 14% increase for all other occupations (see www.bls.gov). The National Council of State Boards of Nursing reports that the number of nursing school graduates who sat for the national RN licensure exam decreased by 31.3% from 1995 to 2002.
The shortage is not just a problem for administrators trying to fill shifts; it’s also a huge problem for patients. A study published in the Journal of the American Medical Association found that each additional patient a nurse is responsible for was associated with a 7% increase in the patient’s likelihood of dying within 30 days of admission. Each additional patient per nurse also was associated with a 23% increase in the likelihood of burnout and a 15% increase in the likelihood of job dissatisfaction.1
"This is a nursing shortage that is not like any other nursing shortage," says Mary Walker, PhD, RN, dean of the Seattle University School of Nursing. "This is the worst nursing shortage we’ve ever had, and the most potentially difficult one to solve. It’s a national public health crisis. When people are sick, they naturally assume there will be someone there to take care of them, and that may not always be the case."
The crisis started in the mid-1990s when hospitals across the country downsized significantly as part of nationwide health care reform. "They downsized beds; they downsized services; they refocused their energies," Walker says. "During that process, there was a lot of national debate around the question, Do we need as many nurses as we have?’ A number of organizations had think tanks, and they all said, No, no, we have too many nurses.’"
Walker says nearly 25% of nursing faculty positions across the country are vacant, and negative images of nursing are hurting student recruitment. She says nursing frequently is seen as a career with little upward mobility, and students are put off by low wages and long hours.
Getting the word out
Ironically, the shortage is both easier and more difficult to cope with in rehab than in other fields, says Paul Nathenson, RN, CRRN, president of the Glenview, IL-based Association for Rehabilitation Nurses. Nathenson also is vice president of patient care at Madonna Rehabilitation Hospital in Lincoln, NE.
"Having the CRRN [certified rehabilitation registered nurse] certification is an advantage. Nurses who are looking more for a profession seek out work areas where there are specialty credentials," he says. "A nurse who has a greater degree of commitment to that specialty will be more engaged and less likely to turn over because another hospital is offering a hire-on bonus. But on the other hand, a lot of people don’t understand what we do in a post-acute setting. Most nurses think they want to work in an acute setting."
Nathenson says every hospital is experiencing a shortage in every area of nursing, and the shortage might just get worse. "We are an aging work force, and rehab is labor-intensive. There is a lot of hard work, a lot of lifting; we’re very hands-on with the patients," he says.
Madonna has about a 5% vacancy rate now, but the rate was more than 10% a year ago. Nathenson says the hospital is fortunate to have students from five different area nursing schools on site for clinicals. Because most nursing schools don’t have a rehab curriculum, it’s important that students experience the rehab setting. But the hospital isn’t resting on its reputation. Madonna has put several ideas to work to address its nursing shortage:
- The hospital publishes its own journal on nursing research. Staff nurses contribute to the journal by reading about research projects and writing abstracts. This serves the dual purpose of recognizing nurses for their professionalism and giving them a venue in which to be published, as well as encouraging them to read about and implement the latest best practices.
- Focus group surveys are conducted regularly to learn what nurses like about their jobs and what suggestions they have for improvements.
- A nurse practice council allows nurses to have significant input into their jobs.
- More attention is paid to retention. Nathenson found that nurses already on staff were not happy that new nurses were offered hire-on bonuses. So he took the money budgeted for those bonuses and divided it among the existing full-time staff for each pay period. An unexpected advantage of that strategy was that a dozen part-time nurses went to full-time hours in order to receive the bonus.
- Madonna pays for the CRRN certification process. If nurses take the course offered on site, they also are compensated for their time.
Switching gears
At Drake Rehabilitation Hospital in Cincinnati, CRRNs are desired but hard to come by, says Mark Goddard, MD, vice president for medical affairs. The hospital has 150 beds, with 40 designated for rehab. The goal is to have 12 CRRNs, but the hospital only has been able to recruit and keep five.
"Part of the dilemma is that there has been a big demand from industry, from insurance companies, from workers’ comp to have nursing case managers who can help expedite rehabilitation care," Goddard says. "It’s been appealing because it’s set hours, nicer hours, and you kind of have a managerial position. What we’ve seen is an exodus from clinical nursing care to more case management."
When young nurses decide to start families, many find pulling shifts is too hard. "You can’t blame them for wanting to go ahead to the next level," Goddard says.
Drake’s response has been to use regular RNs and provide core competency training to instill an appreciation for rehab techniques such as fall prevention. "They become competent in some of the clinical areas, and we try to encourage them to obtain their CRRN," Goddard says.
Rehab can be a challenge to nurses who are used to doing everything for their patients in an acute care setting. "In rehab, nurses have to step back and see what the patients can do for themselves instead of always helping them," Goddard says. "They have to learn to enable and empower their patients, and that’s a complete turnaround from what they are used to. It’s also more time-consuming. It’s much easier to do something for the patient than to teach him how to do it himself."
Drake has 20 unfilled nursing positions and is using agency nurses to fill the gaps. The hospital promotes ongoing education and is establishing centers of excellence that it hopes will attract nurses who want to do research. Drake also is trying to be more flexible when scheduling shifts and has changed the day shift so it ends at 4 p.m. instead of 3:30. "We have therapies from 8 a.m. to 4 p.m., and then the families are there from 4 p.m. to 8 p.m. When the nurses were leaving at 3:30, the families would come in and ask how the patient did that day. Well, the new nurse didn’t know. Now we have better communication."
Reference
1. Aiken L, Clarke S, Sloane D, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002; 288:1,987-1,993.
Sources
Mark Goddard, MD, Vice President for Medical Affairs, Drake Rehabilitation Hospital, 151 W. Galbraith Road, Cincinnati, OH 45216. Telephone: (513) 558-2919.
Martin Harmon, Roosevelt Warm Springs Institute for Rehabilitation, P.O. Box 1000, Warm Springs, GA 31830-1000. Telephone: (706) 655-5668.
Paul Nathenson, RN, CRRN, MPA, Vice President of Patient Care, Madonna Rehabilitation Hospital, 5401 South St., Lincoln, NE 68506. Telephone: (402) 483-9520.
Mary Walker, PhD, RN, Dean, Seattle University School of Nursing, 900 Broadway, Seattle, WA 98122. Telephone: (202) 296-5675.
In August 2002, the Roosevelt Warm Springs (GA) Institute for Rehabilitation found itself with 44% of its registered nurse (RN) positions vacant. The facilitys licensed practical nurse (LPN) vacancy rate was 30%. The institute now has a vacancy rate of 13% for RNs and 10% for LPNs.
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