National health care faces major nursing crisis: It’s time for action’
CMs must be ambassadors for the profession
This is not the nation’s first nursing shortage, but the current nursing deficit threatens to be very different. What’s new this time? American nurses are aging at a time when nursing school admissions have hit an all-time low and the nation’s patients are getting sicker. It’s time, say case management industry leaders, for case managers to start some serious crisis management.
"There isn’t a case manager today who does not see the erosion of quality health care in terms of safety, outcomes, and patient satisfaction," argues Catherine Mullahy, RN, CRRN, CCM, president of Options Unlimited, a case management company based in Huntington, NY, and president-elect of the Case Management Society of America (CMSA) in Little Rock, AR. "As professionals," she explains, "we have a strong responsibility to advocate for those individuals who are now or in the future will be recipients of that health care delivery system."
Without an adequate pool of RNs, notes Mullahy, "our very case management plans are in jeopardy — to say nothing of our patients themselves. There will be a trickle-down-and-out effect as we look to others who are less qualified to put our plans in motion."
Sandra L. Lowery, RN, BSN, CRRN, CCM, president of CCMI Associates, an independent case management company in Francestown, NH, and national president of the CMSA, adds, "Case managers of all disciplines should support any and all efforts to increase the capacity for health care services that are needed or we will not be able to achieve our goals."
Health care professionals have a responsibility, agrees Jacqueline J. Birmingham, BSN, MS, RN, CMAC, executive director of Continuum Care Services in Suffield, CT, to "safeguard patients, and the nursing shortage must be addressed. Unfortunately, nursing has done little until now to upgrade its image and functions, to align itself with the available changes in technology. We’ve groaned and moaned enough — it’s time for action."
Barbara A. Kuritz, RN, CCM, clinical manager for national accounts with Aetna in Philadelphia, encourages case managers to actively take steps "to counteract the nursing shortage. We must be ambassadors for our profession in all of our social interactions. This is essential to recruiting qualified people into nursing and case management."
How real is this nursing shortage? Birmingham’s alma mater just closed its doors after 60 years of nursing education due to diminished enrollment. And that’s just one disturbing sign of the rocky days ahead. Consider these facts pulled from the current literature:
- The number of nursing graduates taking the nursing exam in the state of Georgia dropped from 2,062 in 1997 to 1,130 in 2000.
- There was an overall 13.6% decline in the total number of nursing school graduates between 1995 and 1999.
- The Division of Nursing of the Bureau of Health Professions in Rockville, MD, predicts demand for full-time equivalent RNs will begin to exceed supply by 2010.
- The present average age of employed RNs is 43.3 years, with RNs who are less than 30 years old representing only 10% of the total nurse workforce.
- The majority of nursing school associate and assistant professors are between 49 and 52 years old. (Selected references appear at the end of this article.)
Who will do CM?
Not only does the impending nursing shortage have grave implications for the quality of direct patient care, it also directly affects who will provide case management services. Case management has always been a multidisciplinary health care profession. However, more than 60% of the respondents to the American Health Consultants/ CMSA 2000 Case Management Caseload Survey were RNs. Another 32.6% reported having a bachelor’s or master’s level preparation in a health care profession, and the vast majority of those respondents held degrees in nursing. (For more details, see "CMs respond to national survey," in this issue.) If nursing school enrollments continue to decline, where will tomorrow’s case managers come from?
"Anticipating a shortage of qualified individuals in nursing and in case management, I think there will be those who feel they may have to accept less and lower the bar on requirements and expectations for health care staffing," notes Mullahy. "I believe the CMSA needs to maintain its standards and to publicly, through position statements and press releases, underscore how important we believe it is to have qualified individuals providing services in these advanced practice settings."
The CMSA clearly does not advocate that case managers must have a nursing background, but rather advocates that case managers must have a background in a health care profession. "CMSA does not limit the qualification to practice case management only to RNs," notes Peter Moran, BSN, MS, RN, Cm, CCM, nurse case manager with Harvard Pilgrim Health Care in Wellesley, MA, and chapter president’s representative for the CMSA. "I support having case managers trained in a health care profession — not necessarily nursing."
The nursing shortage may not only change who does case management, but also what case managers do, suggests Linda DeBold, RN, MSN, ARNP, ABQAURP, regional manager of case management for Broward General Medical Center in Fort Lauderdale. "I see the role of the case manager becoming more clinical and less social work related — especially in the acute care setting — in order to accomplish the necessary components of safe discharge. The very fact that we are faced with nursing units staffed with fewer RNs means the responsibility must shift to the case manager to be the strong link in the discharge and in efficient treatment plans being carried out."
No matter what their personal views on which health care professionals make the best qualified case managers, most case management industry leaders support efforts to actively recruit new nurses. The first step to reversing this disturbing trend may be understanding the factors leading to the current decline in nursing school enrollment and nursing staff recruitment and retention.
Moran and Mullahy cite the following factors as contributing to the current nursing crunch:
- lack of prestige associated with the nursing profession;
- more diverse opportunities with better working conditions available to qualified applicants;
- sense of powerlessness to change a failing health care delivery system;
- practicing RNs discouraging young people from entering the profession.
Several national nursing associations, including the American Nurses Association (ANA) and the American Organization of Nurse Executives, both based in Washington, DC, formed a coalition called the Tri-Council and released "Strategies to Reverse the New Nursing Shortage," a white paper which defines and suggests countermeasures for the current nursing crisis. (Information on the white paper, as well as several other useful resources addressing the nursing shortage and the future of health care, appears in "Resources help you take action now," in this issue.)
Recommendations advanced in the Tri-Council white paper include:
- developing career progression initiatives for nurses that move nursing graduates to graduate studies more rapidly;
- identifying the range of options available to nurses beyond entry-level roles;
- instituting an education and practice system which promotes more equitable compensation for nurses;
- reaching out to youth through counselors, youth organizations, schools, and community groups to promote nursing students;
- rewarding experienced nurses for serving as mentors and preceptors;
- establishing appropriate management structures within the health care system to ensure adequate staffing and providing nurses with autonomy over their practices;
- advocating for better identification of registered nursing services within Medicare, Medicaid, and other reimbursement systems;
- investigating the possibility of using technological advances to enhance the capacity of a reduced nursing workforce.
Local solutions to national crisis
Anne Llewellyn, RN-C, BPSHA, CCM, CRRN, CEAC, owner and independent case manager with Professional Resources in Management Education in Miramar, FL, urges case managers to go out into their communities and local schools. "Case managers who are nurses can partner with efforts launched by groups such as the ANA, large hospital systems, and regional organizations to improve the image of nursing among young people."
Moran adds that case managers should take an active role in local, state, regional, and national efforts to address the nursing shortage and other problems within the health care delivery system. "Attend town meetings and national policy meetings," he urges case managers. "In two states in which I am licensed, Massachusetts and Maine, RNs have been asked to decide whether to remain part of the ANA or consider splintering off from the ANA and focusing their resources at a state and local level. In both votes, RNs chose to stay affiliated with the ANA, but the debate continues.
"Within case management we have the recent formation of the ACCM [Academy of Certified Case Managers], an organization set up for certified case managers’ only. I feel these movements to splinter national professional associations are a mistake," argues Moran. "I believe to be truly able to impact decisions on health care we need to be invited to sit at the table and be part of the discussions. If we are not represented at all levels, our interests and concerns will not be heard."
Mullahy also encourages case managers to add their voices to the national debate on health care quality. "We need to be much more active than we have been willing to become. For example, we now have Health Insurance Portability and Accountability (HIPAA) and Prospective Payment Systems (PPS) legislation, major rulings that will affect how case managers will work within the delivery system and how individuals will get services," she notes. "Most of us heard rumblings about these legislative issues and adopted a wait-and-see stance, choosing to respond retroactively once we knew how these rulings might affect us.
"Instead," Mullahy urges, "we should assume that virtually every piece of health care legislation is going to impact our patients and the way we provide services. We had opportunities to be involved in the HIPAA and PPS legislation before they were finalized, and we did not step up. I’m not certain that these legislative initiatives will improve things for our patients; in fact, it appears to make our already convoluted system even more complicated. Now, we are faced with the nursing shortage — we must be included as solutions to the crisis are proposed."
Moran also advocates for active recruitment of new case managers. "I believe we have a good story to tell and must be more proactive about telling others who we are and how we can positively impact outcomes for clients," he stresses. "We must welcome new members and not eat them up and spit them out. We must get out into the community and let people know what we do. And, we need case managers to volunteer to mentor peers and new case managers as they enter the field."
Case managers also can help their friends, family members, and clients take a more active role in safeguarding the health care services they receive, notes Llewellyn. "I assist friends and family members in finding resources in the community with good providers who have proven their reliability," she says. "Also, I educate people about their need to be alert while navigating the health care system. I urge them to ask questions, read information, and take part in the process. Now is not the time to be passive!"
Patient support crucial
Families and other social support systems will be increasingly important as we begin to feel the impact of the nursing shortage, agrees Jeanne Boling, MSN, CRRN, CDMS, CCM, executive director of CMSA. "Currently, it is not advisable for a person to enter an acute care setting without someone to advocate for them while they are compromised. As a practical matter, she adds, "patients can no longer depend on their health care institutions to provide that advocate. The worsening nursing shortage will only emphasize that fact. Families and extended community lay support will become increasingly vital to good outcomes in the near future."
Mullahy agrees, adding, "We’re already seeing nonprofessional, more technical personnel, whether personal care assistants, nursing technicians, or other paraprofessionals, at the bedside instead of nursing professionals. It has become accepted to have a non-nurse perform tasks that previously no one would think of having them perform. Nurses objected, but not strongly enough when these changes were instituted."
A local New York newspaper recently reported that serious surgeries are being routinely rescheduled at local hospitals due to the nursing shortage, she relates. "The article cited problems at other regional hospitals, where, if nurses coming off eight-hour shifts balk at staying to work a second shift, supervisors may threaten them with patient abandonment charges."
Nurses, Mullahy explains, have not traditionally been outspoken self-advocates. "Nurses must educate consumers, physicians, and health care administrators, in terms they will understand, whether those terms relate to improved quality of care, dollars saved, or improved business operations, on the contributions of nurses and case managers. Until that happens, no one will really understand how serious this situation has become."
Selected references
American Association of Colleges of Nursing. Faculty shortages intensify nation’s nursing deficit. 1998, Issue Bulletin: Washington, DC.
Moses E. The registered nurse population: Findings from the National Sample Survey of Registered Nurses, 1996. 1998, Health Resources and Services Administration, Department of Health and Human Services: Washington, DC.
National Advisory Council on Nurse Education and Practice. Report to the Secretary of the Department of Health and Human Services on the Basic Registered Nurse Workforce. 1996, Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing: Rockville, MD.
National Council of State Boards of Nursing. Licensure and Examinations Statistics. 1994, 1995, 1996, 1997, 1998, 1999, 2000, National Council of States Boards of Nursing: Chicago, IL.
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