Quality Talk
Quality Talk
In our recent three-part special report, "Cost vs. Quality," we featured data from the study by Judith Shindul-Rothschild, RN, CS, PhD, "Where have all the nurses gone?"1 This month, she joins us for a discussion of how nursing shortages and work redesign programs affect quality of care. She poses fascinating and bold solutions to cost-containment in health care.
Shindul-Rothschild is a prolific author and researcher, as well as assistant professor at Boston College School of Nursing. Currently on sabbatical, she is updating the above-mentioned nursing study. (See QI/TQM’s three-part series "Cost vs. Quality," June 1999, pp. 65-70; July 1999, pp. 77-83; August 1999, pp. 89-95.)
Q. In your opinion, what are the reasons for the current shortage of nurses?
A. It’s both a supply and a demand problem. On the supply side, the number of young men and women going into nursing is dropping. That’s a big problem. Why we can’t attract people into the profession is something we need to deal with. Then on the demand side, shortage is particularly a problem in skilled areas of hospitals such as intensive care units, coronary care units, and neonatal ICU units. The level of expertise required in today’s tertiary settings is extraordinary. So, we need a highly educated, highly skilled work force. That takes time, and it’s extraordinarily expensive. This is why a lot of universities are dropping their nursing programs. You need very high numbers of faculty. Except for medical schools, nursing is the most costly department to run in a university.
Q. Do you — or anyone else — have an inkling about why we aren’t attracting young people into the profession?
A. The simple response is that there are many opportunities for men and women in other fields. Unemployment is at an all-time low. The service sector industries are burgeoning, so people are trying different things.
Here at Boston College, for instance, the pool of 18-year-olds that comes into the undergraduate program is shrinking, but we just started a new program for what we would call mid-career people. It’s called the accelerated program. We take men and women who already have baccalaureates, masters, and some who have PhDs in other fields. We have them do their basic nurse’s training in one year and then go straight into a master’s program.
The number of applicants is absolutely astounding. The age range of our first group was anywhere from 24 to 44. They are very clear about why they want nursing. They’ve tried other fields; they’ve worked in other service-sector industries and have been very disappointed at the lack of personal fulfillment they’ve experienced in these other careers. Now they are choosing nursing as a way of finding more meaning in their work and are very excited about coming into nursing as a career.
So, it’s almost as if people have to mature a little bit to sort out what they’re really looking for in work. Ten, 15, or 20 years down the road, maybe after they finished their undergraduate program, these students see nursing as a very viable program for them. That’s a potential talent pool I think we need to look at more carefully.
The downside is the abbreviated work life of those folks. You’re investing a lot in education and training for people who will probably have, for all intents and purposes, maybe half the number of years in the work force as an 18- or 19-year-old. You have to look at supply, demand, and retention in order to address the nursing shortage comprehensively.
Q. Are health care organizations doing all they can do to keep nurses on the job?
A. One finding in my survey, which I think is very ominous, is the number of nurses that said they wouldn’t be staying in nursing. And that question was posed to nurses throughout the chronic shortages we had during the 1970s and 1980s. In all those studies, including my own, you would see between 84% and 92% of the respondents saying that they anticipated that they would be in nursing in five to 10 years. In my American Journal of Nursing study, that dropped to around 75% or 76%. That’s a 10% drop. When you extrapolate that out to nurses currently in the work force, that’s a very serious problem.
That’s what I was quite concerned about when all the proposed work redesign models were offered in the early 1990s as a way of increasing productivity and streamlining costs for hospitals. In the short term, when you force people to work harder and work faster with fewer resources, yes, you save money. But there is a terrible cost attached to that. It’s especially terrible in service-sector industries where human capital, the skills and talent people bring to an organization, is the most valuable asset any organization has. And that is certainly true for hospitals.
That short-term saving has to be measured against the long-term cost of losing the most valuable asset in the hospital. And nurses are leaving in droves because the quality of their work life deteriorated so precipitously under these new work designs. Frankly, I don’t know if hospitals can respond fast enough to repair the damage they’ve done. We have seen extraordinarily talented nurses go out the door, and they are not coming back.
Q. Where are they going?
A. Nurses have a lot of skills that are transferable to other service-sector industries. Along with the clinical skills, there is a therapeutic use of self. How you approach somebody and educate them about their illness, and support their family through chronic illnesses or life-threatening illnesses, can make a tremendous difference. Those types of therapeutic skills are easily transferable to other service-sector industries, whether it’s in real estate, in running a business, or in technology. Many nurses who work in high-tech units are very comfortable with technology.
Nurses have to think on their feet and be very well-organized. They have to be astute in terms of assessing a situation and intervening quickly. They are not procrastinators, and they know how to work with people from very diverse backgrounds. So, they are a real asset to an organization. And they are finding alternative employment that doesn’t impinge upon their family life and personal life.
If you asked me what’s the one thing that has pushed nurses over the edge, I would say it’s the mandatory overtime. However, this is strictly speculation on my part from reading the qualitative analysis. Instead of hiring enough staff to fill the slots, organizations impose persistent, mandatory overtime. That’s backbreaking for nurses. That’s where they just throw in the towel. The complaint about mandatory overtime is not unique to health care, but any organization pays a price for that kind of management strategy.
Q. Aren’t we also facing a huge wave of natural attrition as the nursing work force ages?
A. The nursing work force is aging. The average is 44, and we will probably hit 45 before next millennium, where it’s 38 in Australia. Last summer, I attended meetings in Australia, and they were astounded when they learned the ages of nurses who work in our hospitals.
Again, I think the trend is not unique to hospitals. But nobody would expect a 60-year-old construction worker to work like a 22-year-old. Nor can we expect nurses who are approaching 60 to work and take on the kinds of patient loads — literally and physically — as a 22-year-old.
We have a record number of nurses going out with back injuries because of lifting demands. So you might ask, "What could unlicensed assistive personnel do that could help nurses in their work?" I think part of it is the physical labor. That’s going to be key to keeping personnel on the job, as well as the use of technologies that minimize wear and tear on nurses. The medical devices industry could be finding ways to minimize lifting. We haven’t moved too far here. Other issues around quality of work life for nurses are very important. Work redesign schemes that disempower staff, that don’t use staff at all levels as collaborators in a mutual effort to help people get well, are doomed to fail. Top-down management has never worked in any industry.
The health care industry is under tremendous strain in the United States because of efforts to contain costs. However, there is not a quick fix on the labor side, to balance the budgets.
I think that was promised in the early 1990s by a lot of management consultants who walked into hospitals and said, "We can save you millions of dollars by work redesign and shift in skill mix." Now, 10 years later, we know that was a huge debacle. Lots of research, not only my own, is demonstrating that.
That disaster did not save money; it cost money. It forced our most skilled labor out of hospitals. The outcomes for patients have been terrible! That research is coming out now. It’s very clear that health care can’t be done on the cheap. There have to be other ways of improving efficiencies.
Q. If we don’t find the economies in the labor costs, where else could we look without sacrificing good patient outcomes?
A. I am a strong supporter of a single payer health system because I think that administrative overhead is burgeoning. We cannot afford to have one-third of every American health care dollar eaten by bureaucrats who are paper pushers. There is absolutely no evidence, in any study anywhere, that nurses, or health care workers in general, have contributed in any way to health care costs. When you look at the numbers of nurses we have, and the patient loads that they have to take in this country, we have, by far, the most efficient labor force in the world. There is absolutely no question about that.
The bigger issue is how we can use our health care resources more efficiently to keep our health care costs from galloping out of control. If you want to squeeze money out of the system, then go after the administrative overhead. Everybody agrees it’s extraordinarily wasteful in the United States.
Reference
1. Shindul-Rothschild J, Berry D, Long-Middleton E. Where have all the nurses gone? Am J Nurs 1996; 96:25-39.
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