Imagine No More Nurses

Pamela Valfer

You might not know it to look at them, but Michael and Elizabeth deVera are sought-after commodities: a picture-perfect example of the latest solution to the nursing shortage.

In Minnesota right now there is a shortfall of upward of 3,000 nurses, and that number is expected to more than double in the next five years. Across the country, the figures are terrifying. This year demand for registered nurses is expected to outpace supply by more than 130,000. At present rates that number will be 800,000 by the year 2020.

The deVeras are nurses, well-educated, well-trained, recruited from their home in the Philippines to work in the Twin Cities--to plug the expanding cracks in the crumbling pipeline of registered nurses here. They work the overnight shift on the telemetry floor (a cardiac care unit) at St. John's Hospital in Maplewood.

They have been here a year now and, aside from occasional bouts of homesickness, have only the best things to say about their new lives. They have only good things to say about their employers, their co-workers, and the patients they treat. They are eager for opportunities to advance professionally. They are happy to earn in two months here the equivalent of a year's salary back home.

"I couldn't speak highly enough about them," says Patrice Dailey, the deVeras' boss and clinical director of the telemetry unit. "We've had nothing but positive comments from our patients. They have such a positive attitude because they're so thankful to be here."

The deVeras are two of some 50 nurses recruited by HealthEast Care System to work in its hospitals and healthcare facilities in the Twin Cities. Other recruiters have also brought Filipino nurses to Minnesota to work in hospitals and nursing homes. It's hard to know exactly how many are here, but the Minnesota Board of Nursing says it issued permits to 39 Filipino nurses in the 2002 fiscal year, compared with 29 from Nigeria and just 4 from India. Overall, 436 licenses were issued to foreign-educated nurses in 2002, up from 292 the previous year and the highest number in five years.

Recruiting nurses from the Philippines is a seductive solution to a growing problem. After all, what could be better? They're trained in a curriculum modeled on that of American nursing schools. They speak English, often with only the scarcest accent. And, of course, as members of a "model minority," they are readily accepted as quiet, smart, and hardworking. In short, it is not hard for them to fit in.

It's no wonder that in the midst of this crisis American hospitals are looking overseas for bodies to beef up their staffs. But it's precisely because the solution is so appealing that it's so dangerous. Recruiting nurses from the Philippines is just one more in a series of Band-Aids for a massive nursing shortage that's been brewing for a long time. It doesn't address the reasons behind the shortage--the deliberate cost-cutting practices of hospitals and HMOs, the entrenched balkanization of nurses--and it doesn't do anything to fix those problems in the future.

"We go to Mexico to get our orange tree workers, India to get our software designers, the Philippines to get our nurses," says Steven H. Miles, M.D., a professor at the University of Minnesota's Center for Bioethics. "But it's a stopgap measure. We've blown an opportunity to make the structural repairs at home by patching over with the Philippine solution."


According to a July 2002 report from the U.S. Department of Health and Human Services, nursing in the United States has a bleak future. For starters, the report takes a look at nurses' salaries. The comparison of choice--with elementary school teachers--is revealing; if you thought the people who shape young minds are underpaid, wait until you see how we compensate the folks who hold your life in their hands. "In 1983, the average elementary school teacher earned about $4,400 more than the average RN; by 2000 this had grown to the point where elementary school teachers earned about $13,600 more," the report states. (In 2000, the average nurse's salary was $41,080.)

But there are other telling statistics. From 1995 to 2000, the number of registered nurses graduating from nursing schools fell by more than a quarter. And nurses are getting older: In 1980 25 percent of nurses were under age 30; in 2000 it was a mere nine percent. Today the average age of a nurse is in the mid-40s. In addition, the number of nurses who are losing or simply giving up their licenses is skyrocketing. The loss of nurses from the license pool grew sevenfold from 1996 to 2000, and by 2020 more nurses will be leaving that pool than entering it.

Cynthia Barnes is 61 years old. She's been a nurse since 1965. She has delivered babies, sat beside patients as they died, treated countless sick people, helped their families cope. She decided, at age three, that she wanted to be a nurse, and she's never swayed from that determination. She loves what she does. The wages, she contends, are decent, and the schedule is fairly flexible. But on more and more days, Barnes's job seems not just difficult, but near impossible.  

"It's crazy. It's frenzied," says Barnes, a nurse in the intensive care unit at United Hospital in St. Paul. Though staffing levels, which in the ICU are one or two patients per nurse, have been adequate of late, Barnes has had her share of moments when the nursing shortage hit home.

"It's frightening when you cannot care for the patients under your care, and something could happen," Barnes says. "You can't be in two places at once."

There's a constant concern that something is happening with a patient that Barnes doesn't know about, or can't get to.

"I went into one patient's room, and his blood pressure was 50; that's not conducive to long-term existence," Barnes remembers. "A monitor was beeping, but no one heard it. You can't be everywhere."

Sometimes, when the unit is terribly busy and there just aren't enough nurses to pick up the extra work, Barnes explains, it's a struggle to make sure the patients get their medications on time. Forget about bathing them or brushing their teeth.

"The goal, if you're short, is not to make any errors in medication or treatment. Probably what you let go is the comfort of the patient," Barnes says. "You can't do nursing the way you used to do--give that personal care. You can't make the patient feel like you're there."

Hospital patients today are sicker than ever before, as insurance companies now pay for in-patient stays in only the most dire cases. The situation can only get worse as the population ages and baby boomers start needing more intensive medical care.

The job itself has grown harder, too. Medical technology has become elaborate and omnipresent, medication schedules more intricate. On top of that there's the unyielding bureaucracy and the ever-increasing mound of paperwork nurses must complete in order to meet administrative standards. Though staffing has improved in recent years, it's still very common for nurses to work double shifts. ("There's no mandatory overtime in our contract," notes United float nurse Karmen Rushton. "But that doesn't mean they can't make you feel bad. You don't want to leave your friends hanging.")

It's easy to understand why nurses today are exhausted. Why many of them opt for jobs with nursing agencies, where they can control their hours. Or with hospice or home healthcare programs, reducing the number of patients they care for. Or why they choose to leave the profession entirely.

It's easy, too, to understand why Cynthia Barnes is worried that there won't be anyone to replace her when she finally decides to retire.

Sara Brazil might have been one of those up-and-coming nurses. For her it wasn't a lifelong dream to be a nurse, but she had always been interested in health care. After earning her four-year college degree and working several jobs throughout her 20s, she decided to go back to school to get her nursing degree. "I did it for practical reasons, as well as I just think it was good work to do," the 37-year-old recalls. "It was this everyday-place job where I go, but also an opportunity to make a difference."

For four years she worked as an oncology nurse at Abbott Northwestern Hospital. She worked her last shift on Christmas Eve 1999.

One of the main reasons she quit? The nursing shortage.

"It wasn't just a drag, it was a peril," she says, recalling her time on the night shift. "It was really getting to a level where it was scary to be there. At nighttime, we were almost never at what's considered to be the minimum staffing level. It sometimes felt like you couldn't keep an eye on all of your patients."

To make matters worse, the patients in the hospital seemed to be frailer, their conditions more critical, and turnover among nurses grew steadier, until Brazil was one of the senior staff members. "I had four years of part-time experience. I still felt there was a lot I was still learning," she remembers. "I did not feel ready to be the floor resource.

"You were scared," Brazil continues. "You didn't want people to get hurt, and you didn't want to get in trouble if something happened. And you felt sad because you weren't doing what you wanted to be doing. Most nurses don't want to be task-doers. What you really wanted to be able to do was spend time with people, support them emotionally. Visit with them if they're bored or lonely. That's a big part of healing. That's a big part of being a nurse.  

"Rationally, you knew it wasn't your fault, but you went home unsatisfied," Brazil remarks. "Even though you never worked so hard in your life and got so many tasks done."


Perhaps the biggest change in nursing over the past few years is that people are at least talking about the shortage, both locally and around the country. In the Twin Cities it was a hot issue during the 2001 nursing strike. And, while Barnes and her colleagues say the staffing situation is better today than two years ago, the nurses' union had to bring local hospitals to their knees for three weeks in order to get anyone to listen to them.

National research has sparked conversation about political remedies. That research is sobering: Last fall a much- publicized University of Pennsylvania report directly linked patient mortality to the number of patients under a single nurse's care. The study, published last October in the Journal of the American Medical Association, found that if nurses try to care for more than four surgical patients at a time, the chances of those patients dying rise--by seven percent per additional patient.

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.

"There's no reason," he continues, "why you couldn't create a program that could take a nurse's aide and give them work-study credit to advance to a two-year nursing program, or a four-year nursing degree. You could offer an accessible career ladder for people who have relatively few workable career ladders on the way up to the middle class."


Although some immigrants, from Africa, Asia, and Eastern Europe, struggle to make ends meet in low-paying positions, others, like Michael and Elizabeth deVera, are coveted and lured into coming to America.

"Even though there are openings here in America, I am not interested in coming here. I will just miss my family. I'm a home... home... What do you call that?" murmurs Elizabeth deVera, who, at 27, could pass for a teenager. (Her HealthEast employers, sitting beside her as she talks, quickly assist her with the term, "homebody.") "But then I met Michael."

Her husband had no such reservations.

"There's this goal of coming over," says 30-year-old Michael deVera, large brown eyes beaming as he flashes a winsome smile. "There's an opportunity to advance. And I already serve my country, sending our hard-earned money for our families."

The Philippines is a special case. Unlike most countries, the Philippines has a surplus of nurses. In fact, the Filipino government encourages citizens to go into nursing for the sole purpose of going overseas, so they can send money back to their homeland. (Exporting employees, from nurses and engineers to hairdressers and farmers, generates billions of dollars for the Philippines each year; Wired reported last year that remittances from Filipinos working overseas make up as much as eight percent of the country's gross national product.) It's no wonder, then, that recruiters from the United States, Europe, and the Middle East gladly converge on the South Pacific archipelago to entice nurses to their countries.

Recruiting from the Philippines does require time and money--it can take up to two years for the nurses to jump required immigration and licensure hurdles--but for Twin Cities hospitals it's less expensive than paying excessive signing bonuses to local nurses or paying exorbitant fees for temporary-agency workers when staffing levels fall dangerously short. Besides, once the nurses are here, the investment tends to pay off. At HealthEast, for instance, the Filipino nurses have a 40-month contract with the hospital system.

Abraham Abbariao, whose company Midwest Clinic Management brought the nurses to HealthEast, began recruiting nurses from his Filipino homeland quite by accident. His Bloomington-based consulting firm had worked with HealthEast, and a few years back, when the system began looking into international recruiting, Abbariao offered to scout out the Philippines. Now, he has sprouted an ancillary business doing just that kind of recruiting, having hired 100 nurses, with nearly 400 more ready to be interviewed for positions in Kentucky, North Carolina, and New York. "It's the choice for U.S. hospitals," he says matter-of-factly. "To have nothing, or have something."  

But the popularity of the Filipino panacea raises concerns. The Minnesota Nurses Association, for instance, worries that once nurses arrive, from the Philippines or other countries, they may not be given the support they need to adjust to their new country. Moreover, critics challenge the overseas recruitment, calling it unscrupulous for the United States to pillage Third World countries for its own gain. Even though the Philippines may have a surplus of nurses today, that is not always the case in countries where the U.S. recruits nurses, including South Africa.

"If we're recruiting [from overseas] just to handle a nursing staffing crisis at bedside, we do have a problem with that. America is putting its interest ahead of others' to the point of being unethical," says Jan Rabbers, spokeswoman for the Minnesota Nurses Association. "We have got to grow nurses. We have got to keep nurses. We have got to change health care."


A start, says Joanne Disch, a professor and administrator at the University of Minnesota's School of Nursing, would be devoting more resources to train new nurses. And, even more important, nursing schools need an influx of funds to train nursing faculty, a population that's also dwindling.

But it's more than just creating new nurses, Disch adds. To keep those nurses from burning out, hospitals and healthcare systems need to fundamentally change their environments. The dogmatic hierarchy needs to change and nurses must be able to collaborate more with physicians in the administration of health care. "Nurses need to be more fully integrated into the organizations in which they are practicing," she says. "Nurses want more control over their schedules. They want to have a say in how things are decided with regard to patient care."

On that point, Kip Sullivan agrees. "Pay ought to be increased," he says. "Nurses ought to have more authority."

Beyond that, he insists that forcing hospitals to control spiraling costs and restructuring the health insurance industry can go a long way to solving the nursing shortage.

Of the $1.5 trillion spent annually on health care in the United States, anywhere from 20 to 40 percent is wasted on out-of-control administrative costs, excess hospital beds, underused expensive equipment, and outrageous drug prices, Sullivan argues. "Compared to the $300-$450 billion being wasted, I am positive that the amount of money it would take to get nurse-patient ratios up to safe levels is a pittance," he says. "If we controlled drug prices, we could save enough money to solve the nursing shortage."

Perhaps within the next 20 years hospitals will be subjected to budgets, helping to control costs, Sullivan suggests. And maybe, he muses, within 30 years the United States will move to a single-payer system of health care. But for that to be more than just a fleeting notion, the healthcare industry--and the government--must get moving.

"This is a huge social problem now, and when the baby boomers retire, it has the making of a disaster. And nobody is holding hearings, nobody has released a blueprint to solve the problem," Sullivan says. "Nobody wants to take a long-term view and say 'this is how it's got to happen' and put money there. It's going to get worse before it gets better."

For his part, Miles agrees that governments have failed on this count. "There is a complete collapse of forward-looking government on a state and national level." But, he stresses, he's fairly hopeful that a change may be in the offing. Most of the pieces are already in place to direct nurse's aides toward nursing careers, he maintains. It's just that industry and educators will need to work together. "Of all healthcare reforms, this one strikes me as one of the most immediately doable," he says.

"Nursing is just a neat thing to do," muses Miles. "It's better than sitting in a cubicle and being a telemarketer."

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