Nursing shortage: It’s likely to get worse before it gets better
Experienced, specialized nurses in very short supply
The numbers don’t lie; the nursing shortage is real. According to a recent Washington, DC-based American Hospital Association (AHA) poll, there is an 11% vacancy rate among registered nurses in the United States. (For more on the AHA report, see "AHA confirms nursing shortage," in this issue.) And the problem is even more pressing for managers of occupational health facilities, who require the help of nurses with specialized experience.
"When we look to place nurses, it’s becoming more and more of a challenge to find experienced occupational health nurses who can go on-site independently," explains Ginny Lepping, RN, MBA, COHNS, executive vice president of Providence Occupational Health Services in Granite City, IL. Providence Occupational Health Services is a for-profit hospital-affiliated occupational health program.
In addition to its clinic environment, it provides prevention and rehab services, work conditioning, job site analysis, employee assistance programs, and it operates a wellness center, as well as placing nurses on-site. "Typically, our nurses must have a very strong clinical background as well as management and financial skills," says Lepping. "The challenge has been to find someone with that expertise, especially when there are fewer people coming into the profession in general."
"There are simply not enough nurses to go around," explains Rachelle Rolshoven, RN, director of YOH Health Care in Sherman Oaks, CA, which provides contract and relief occupational health nurses to business and industry. Rolshoven also is president of the Southern California Chapter of the American Association of Occupational Health Nurses (AAOHN).
The shortage, she says, stems from two separate dichotomies:
"First, occupational health has been around for some 50-plus years," she says. "A lot of nurses who originally started out in oc health’ are now retiring, leaving a big void in the availability of qualified nurses. [Second], there are not a lot of nursing programs that teach occupational health, so if you’re a nurse trying to get into the field, it is sometimes difficult, depending on your background. An emergency room or emergent care background some- times makes it a little easier, but there are big gaps in workers’ comp and [Occupational Safety and Health Administration] expertise.
"Some of these nurses can be pulled in and trained quickly, while others take more time," Rolshoven adds. (For the American Organization of Nurse Executives’ recommendations on combating the nursing shortage, see "Publication paints a bleak picture," in this issue.)
The situation will get worse
As bad as things are, they are going to get even worse. Experts agree that the demographic changes ahead will exacerbate the lack of experienced nurses for occupational health facilities.
Deborah V. DiBenedetto, president of the Atlanta-based AAOHN, is emphatic about focusing on the future. "No. 1, there’s a lot more publicity about the shortage than the current situation might warrant," she notes. "The shortage is not that dire now, but it is projected that by 2008 and beyond, there will be a severe shortage as Boomers start to attrition out and people continue to leave the profession. There is increased difficulty in hiring bedside nurses, and the negative press offers an additional disincentive." Also, she points out, women today have more job options, many of which offer better pay, more job satisfaction, and perceived better working conditions.
Rolshoven suggests that the shortage is "probably not as apparent in occupational health as it is in other areas of nursing, only because we are such a small portion — perhaps somewhere between one-fifth and one-tenth — of the total nursing population."
The current situation has significantly affected the hiring practices at occupation health clinics, and placed upward pressure on salaries, note observers. "Instead of using registered nurses, we’re going to LVNs [licensed vocational nurses] and LPNs [licensed practical nurses]," says Rolshoven. "Some clients have gone to using paramedics, so we’re moving down the ladder, so to speak, as to the educational background of people.
Paying for quality
"In the long run, I assume it’s cheaper for them to do that, since we pay LVNs about 75% of what we pay RNs, but I don’t know that the quality of care is quite the same. I don’t think that someone with four to six months’ training as a medical assistant can provide the same quality of care as someone with two to four years of nursing education; it’s a totally different knowledge base," she says.
"One of the things companies are doing now is hiring EMTs and paramedical people," Lepping adds. "Certainly from an occupational health nursing standpoint, these people are not equally prepared to provide the same quality of care or breadth of service."
Some ED nurses are interested in picking up additional time, she notes, and will do weekend or evening occupational health work, but that resource will dry up soon because the medical centers will ask them to do the same thing. "We’re all going after the same resources, which will also drive up salaries," she predicts.
Salaries already are on the rise, says Janie Blackman, vice president of Park Med Occupational Health in Knoxville, TN. Park Med has two lines of occupational health services. The company provides nurses at construction sites and in business and industry, and it also operates an occupational health medical call center that is staffed by registered nurses around the clock. Park Med also owns several walk-in clinics that combine occupational health and general health services.
"Nurses are getting harder to find, and they are demanding more money," Blackman says. "If I have a contract with a company to provide on-site nursing, I am limited by that contract as to how much I can pay the nurses. If I have a 10% profit built in and have to pay a nurse 20% more than I projected, I not only do not break even, but I go in the hole. And, basically, that’s my problem."
From her perspective, she has things tougher than managers of hospital-based clinics. "They are not affected to the same extent we are," she asserts. "They have a larger pool of nurses who want off’ the floor. In fact, some nurses might even be willing to take a cut in pay just to get off the floor!"
"I went through [a nursing shortage] in the ’70s, and salaries did go up," recalls DiBenedetto, "But what happened was they got rid of ancillaries like nurses aides. For every two hands that disappeared, we only had one left. But the demand for quality in health care demands a better qualified individual, so you have a Catch-22. Salaries will go up."
What’s also a growing trend, and perhaps of greater concern, is the limited ability of nurses to make changes in their job tasks." This is causing a lot of dissatisfaction and burnout," DiBenedetto notes. "The biggest issue is that we’ve moved to 12-hour shifts when nurses were plentiful, but there’s a decrease in patient continuity and lack of morale because we’re finding perceived patient safety issues. Stress levels are high; absenteeism is high," she says.
Solutions, anyone?
So, what’s to be done? Are there any short-term solutions to the problem? And if not, how can we help the nurses who remain on the job? "We can help mitigate these effects," suggests DiBenedetto. "For one thing, we have to have employee health services available to nurses, or programs from an occupational health and wellness perspective that screen for changes in behavior and effects of high stress levels. We should also have [employee assistance programs] available; they can be our best friend in terms managing employee health and safety."
Unfortunately, she says, the penetration rate of such programs in hospitals is just 2% to 3%. "There is a severe curtailing of access to emotional health benefits," she says.
To directly address the shortage in California, "We are trying to use some mentoring programs," says Rolshoven. "Our association is trying to reach out to student nurses throughout the state, to try to educate them about the field of occupational health. "There are a couple of certificate programs in occupational health we refer people to frequently. UCI [University of California-Irvine] and UCSD [San Diego] are very helpful in getting the basic information. There also are programs for nurse practitioners at UCLA [Los Angeles] and UCSF [San Francisco]," she continues, "But that’s a step above the RN. They will get higher salaries, as they can write prescriptions, do physical exams, and work independently."
"In the past, we have had a mentorship program with a local university," says Lepping. "Nurses who had gone back for their BSNs would be part of our program for a semester. This was an opportunity to groom people to use on call or hire in as part- or full-time employees, but with fewer people coming into the school of nursing we have fewer people to draw from. One of the things we’ve thought about doing was offering mentorships within our own program if nurses outside the nursing school environment were interested in it," she continues. "But so far, we’ve not had the need to do that."
"The key for occupational medicine clinics is to hire non-RNs and train them for other tasks," offers Bill Patterson, MD, MPH, FACOEM, chair of the medical policy board at OH+R in Wilmington, MA. "Often, the most valuable person is an respiratory therapist, who can then be trained to do pulmonary function tests, audios, phlebotomy, drug and alcohol testing and collection, and other routine tasks. Cross-training is a key in the efficient management of an oc med clinic."
Patterson adds that his organization is finding that "[certified occupational health nurses] are best at on-site activities, where their broader knowledge of the principles of occupational health, prevention, public health, and ability to work independently are valuable assets."
Will the solutions work?
To combat the financial crunch, Blackman says she’s gone back to some of her long-term contractors to try to renegotiate fees. "We try to make them see that financially we can’t continue like this," she says. "No. 2, we’re trying to point out to nurses the benefits of working with us, even though it may be at a lower rate of pay. But that’s tough; one nurse, for example, was making $19 [an hour] with us, while a hospital could hire her at $28 an hour. I can’t compete with that."
The experts are not particularly sanguine about the prospects of overcoming these problems anytime soon. "We may be able to satisfy some of the needs through EMTs, and we see some of the acute care organizations looking to foreign-trained nurses as a short-term solution," says Lepping. "But that’s not an immediate answer for us, because our nurses need to have a very good command of the language. Many actually work as employee advocates, and they need to be aware of the benefits program. The learning curve will be greater than it would from an acute care standpoint."
More job options available to women
"I don’t know if there’s an immediate answer to the problem," says Rolshoven. "Women have so many options now compared to when I went into nursing 20 to 25 years ago. They can do bedside nursing, but they don’t have to. Even with the numbers of nurses available, there are never going to be enough because of all the other career options. You can bring in all the foreign nurses you want and not make up the difference."
Rolshoven points out that as employers, occupational health clinics are a breed apart. "[Hiring foreign nurses] may be alright in the hospital setting, but those nurses don’t know any of the workers’ comp or safety issues. Occupational health will not be seeing relief coming from that area," she asserts. "I would say that in terms of our employers, if we can do something in our profession to help employers recognize the broader value in occupational health nurses, they may see some more wisdom in hiring them," says Lepping, offering one note of optimism.
But Blackman puts the whole situation into perspective. "I’m an old nurse; I’ve been in the profession for 25 years, and it has cycled before," she says. "Over the years, we have had an overabundance of nurses, and then a shortage. But this time, they’re really getting into trouble because of the aging population; we’ve never had to contend with that before.
"Then there are other issues: Why should I go to nursing school, spend four years working at one of the hardest curricula around, and make $32,000, when I could spend the same amount of money and brainpower to become an engineer and make $50,000 or $60,000? Women have options now. The nursing profession may be starting to catch up in terms of pay, but it will be a while before it totally catches up."
[For more information, contact:
• Rachelle Rolshoven, RN, YOH Healthcare, 14140 Ventura Blvd., Suite 250, Sherman Oaks, CA 91423. Telephone: (818) 377-6990. E-mail: [email protected].
• Janie Blackman, Park Med Occupational Health, 431 Park Village Drive, Suite C, Knoxville, TN 37923. Telephone: (800) 818-2648.
• Deborah V. DiBenedetto, President, American Association of Occupational Health Nurses Inc., 2920 Brandywine Road, Suite 100, Atlanta, GA 30341. Telephone: (770) 455-7757. Fax: (770) 455-7271. Web: www.aaohn.org.
• Ginny Lepping, RN, MBA, COHNS, Executive Vice President, Providence Occupational Health Services, 2103 Iowa St., Suite D, Granite City, IL 62040. Telephone: (618) 798-3517.
• Bill Patterson, MD, MPH, FACOEM, OH+R, 66B Concord St., Wilmington, MA 01887. Telephone: (978) 657-3826.]
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