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Another report, released last August by the Joint Commission on Accreditation of Healthcare Organizations, suggested that low nursing levels may have had a hand in as many as a quarter of the unanticipated deaths and injuries of hospital patients since 1996.
Legislation, both nationally and in certain states, has tried to address the nursing shortage. Last year Congress passed the federal Nurse Reinvestment Act, which, while providing some funding to entice more people into nursing, failed to meaningfully address ongoing problems in nurses' work environments. California has passed, but not yet enacted, a law that will mandate a specific nurse-to-patient ratio, probably starting with one nurse for every six medical/surgical patients, with an eye toward reducing the ratio to one nurse for every five patients after a year. And while lawmakers in other states are pressing for similar measures, the problem remains that simply mandating a legal ratio cannot by itself conjure up the qualified nurses to maintain it.
But for the most part the discussion circles around easy answers--signing bonuses, the arrival of foreign recruits. The shortage, too often, is viewed in a vacuum, with little attention paid to its roots--or the fact that it might have been avoided.
"The nursing shortage has several causes, but unquestionably the biggest cause is the high workload nurses deal with," says local writer and health policy expert Kip Sullivan. "And that is a result of managed care.
"To be running off to the Philippines to get nurses is something that has to be done, now that we're in a full-blown crisis," he continues. "But the hospitals should have seen this coming a decade ago when they jumped in bed with the HMOs."
In the late '80s and early '90s, Sullivan recalls, the healthcare industry and government offered burgeoning HMOs large discounts and incentives. As a result, the industry went through a period of unprecedented restructuring--and hospitals and HMOs themselves helped create what now promises to become a crippling shortage of nurses. Incessant cost-cutting, and the shifting of personnel away from nursing and toward an ever more bloated administration, were among the many shortsighted changes that have caused the crisis in health care.
Sullivan cites a seminal study published in the journal Health Affairs in 1996. From 1981 to 1993, the study showed, hospitals in the United States cut their nursing staffs by an average of more than seven percent. The cuts were extreme in some states: as much as 27 percent in Massachusetts, 25 percent in New York, and 20 percent in California. During the same period nurses became a smaller part of the overall hospital workforce, falling from 45 percent to 37 percent.
At the same time, hospitals across the country poured more and more resources into the process side of medicine--increasing administrative staffs by nearly 47 percent.
Nurses on the front lines saw it happen, and they haven't forgotten.
"When I started nursing, we used to be able to sit, converse, commiserate, mentor, and teach," says Linda Slattengren, an orthopedic nurse at United Hospital. "Now I work an eight-hour shift without ever sitting."
Slattengren offers a fairly simple explanation for the shortage. "I think what caused the crisis was they stopped hiring nurses," she says. "It was cutting the budget, cutting the budget."
Fixing the system is possible, Sullivan contends. "We need system reform that takes money away from insurance company overhead, overpaid physician specialists, and outrageous drug prices--that pulls money away from those areas and puts it toward the nurses. It's a pretty straightforward solution," he offers.
"What makes me angry is that the hospital industry refuses to admit it's contributed to this concern," he continues. "Hospitals have got to say, 'This system sucks. We helped create this terrible system. We need to create real reform.' Not just, 'Give us some money to go to the Philippines to hire more nurses.'"
The U of M's Steven Miles agrees that the nursing shortage didn't come out of nowhere.
"The nursing shortage is not an accident. It's not a temporary problem. It's not caused by a transient change in the economy that will go away," Miles says. "It's a deep and structural characteristic of the medical profession."
First off, Miles blames the medical system's long-standing sexism, which for decades purposely steered women into the role of nurse. "We have to acknowledge that the traditional way we filled nursing was by creating a glass ceiling in medicine that is no longer available," he explains, noting that women interested in intensive medical careers today are likely to become physicians themselves. "We need to think of different ways to fill these positions."
But another, even more insidious way in which the healthcare system has squelched the nursing pipeline is by creating an underclass of healthcare semi-professionals. The medical profession has consistently moved healthcare tasks downward, off the shoulders of highly paid professionals. The result, at least on the nursing side, has been the creation of a caste of workers--the nurse's aides--who receive less training, are compensated only about as well as a Burger King employee, and have little or no chance to move up.
"Imagine that you're a new arrival, with a green card, from Nigeria, and you get a nurse's aide job," Miles begins. "It's a job that counts for nothing more than a paycheck. It's not a track up toward anything.
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