Wanted: More Good Nurses

by Pam Auchmutey

Mornings when veteran nurse Carmen Blount crosses the pedestrian bridge into Emory University Hospital and sees admissions overflowing with people waiting for a bed, she just takes a deep breath. The hospital has been full lately, and for nurses that means a juggling act that challenges even the most experienced.

Blount works in the hospital's "float pool," the core of experienced registered nurses who fill in where needed in different units throughout the hospital. "I don't know what I'm going to be doing until that day," she says.

But Blount knows one thing for sure. She will be stretched, even on the best of days.

On this day in particular, she is assigned to the general medicine unit on 5G. Her quadriplegic and stroke patients are almost totally helpless and need to be fed, bathed, and helped with all activities of daily living. Medications must be given, IVs checked, and conditions monitored constantly. Another patient must be prepped for neurosurgery; he's anxious and needs reassurance. Blount has just helped discharge a vascular patient after explaining to her family follow-up care and what to expect at home. A new patient is on his way up to the unit, and Blount will examine him, take his history, and coordinate a battery of tests. And then there's always the paperwork waiting for her.

Most days, Blount cares for four to six patients. But as she will tell you, it's not just the number of patients but the complexity of their care that keep her and other nurses on the run. To compound matters, Emory is feeling the pinch of a critical national nursing shortage.

Blount worries how that affects the delivery of care in an already challenging health care environment. "The nurses here really care about what they do, and they become frustrated when they can't spend more time with their patients, given their numbers and the complexity of their care."

Yet, administrators say that Emory Hospital is better staffed than most hospitals in the metro area and is aggressively recruiting for more nurses. But the fact remains: There just aren't enough nurses to go around. Nationally, the turnover in nursing is at an all-time high, and fewer people are going into the profession as options open for less stressful, higher paying careers.

Like hospitals everywhere, Emory is feeling the pinch of a national nursing shortage.

Name: Carmen Blount
Vital Stats: age 46; experience, 21 years
(South Fulton Hospital, Emory Hospital);
specialty: medical surgery float pool;
also licensed as family nurse practitioner
Last seen: filling in -- float pool, EUH

The median rate for nursing staff turnover increased nationally from 12% in 1996 to 15% in 1998 and is expected to reach 17% in 2000, based on a survey by the consulting firm William M. Mercer. At the time of the survey, classified ads listed approximately 1,000 openings for registered nurses (RNs) at 16 major Atlanta hospitals. Demand was greatest for nurses with highly specialized skills.

"It is harder to find nurses in specialty areas," says Alice Vautier, associate administrator for patient services and chief nursing officer for Emory Hospitals. "It's the experienced nurse in specialty areas - critical care, labor and delivery, emergency rooms, oncology, and surgical services - that hospitals need the most."

In some respects, nursing shortages are old news. Two occurred in the early and late 1980s, caused by dips and peaks in the number of nursing graduates entering the hospital labor market. While hospitals have rebounded before, the current shortage is more complex.

According to national statistics, the majority of experienced RNs are now in their 40s and 50s. Many are working part-time or are leaving the hospital setting to retire, to practice nursing in less demanding health care settings, or to work in another field altogether. Because of managed care, hospital stays are shorter, and the patients who are admitted are very sick, requiring high-acuity care. Also, as the number of older people in the general population climbs, many will need advanced medical care as they age.

A 1996 report by the National Advisory Council on Nurse Education and Practice (NACNEP) to the secretary of the US Department of Health and Human Services (HHS) outlines these trends. In examining the nation's RN workforce, the advisory council predicted a nursing shortage unlike any before by the year 2010. "We're going to see an increase in the demand for nurses at the same time we're seeing decreased availability," explains Emory nursing school Dean Marla Salmon, who directed the HHS division of nursing when the report was issued. "We've entered a very complex shortage. It's not just cyclical demand changes as we've seen in the past. It's both demand-driven and supply-driven."

Peg Bloomquist, associate administrator for Emory Hospitals, sees this daily. "A hospital nurse has to really want to work in an acute setting, which is a 24-hour-a-day operation," she says. "It's a very stressful, hard job. Our patients are sicker, and the care being provided is intense and demanding. Plus the economy is doing well, and more nurses want to work part-time."

Vautier concurs. "We have a number of nurses who don't want to work 40 hours a week. Many prefer to work 24 or 32 hours. As the population ages, more nurses will want to work part-time. Many of our nurses are in their 40s and 50s and will retire soon, It will be difficult to replace the experience of these professionals. We need younger nurses to fill the pipeline."

Age compression is another factor. For the first time, more than half of the nation's nurses are 45 years old, while less than 10% of nurses are under 30. Nurses are also entering the workforce at a later age to start second careers or to continue working after having children. "Not only do we need more nurses because nurses are leaving the field, but we need more nurses because they are working for a shorter number of years," says Salmon. "So instead of being able to depend on a new graduate having a 40-year career in nursing, that person may have a 10-year or a 20-year career in nursing."

Experience needed

As RNs retire or leave to practice in less demanding settings, hospitals need experienced nurses in critical care, labor and delivery, emergency rooms, oncology, and surgical services.

Name: Chris Coppinger
Vital Stats: age 36; experience, 16 years
(Emory Clinic, Brigham and Women's Hospital); specialty: nurse practitioner,
Last seen: educating patients about their
treatment for cancer -- gynecology/
oncology, The Emory Clinic

Nursing employment patterns have also changed, note the NACNEP and the American Nurses Association. Although hospitals still employ the largest number of RNs, the proportion of nurses working in hospitals dropped noticeably from 67% in 1992 to 60% in 1996. In contrast, the number of RNs working in nonhospital settings grew during that period. The largest increases occurred in home health care (65%) and community health care (43%), followed by city and county health departments (33%), nursing homes (32%), and public schools (29%).

The refocus of the health care delivery system has affected how nurses do their jobs, the NACNEP observes in a recent report to the secretary of HHS. Traditional emphasis on acute care in hospitals has shifted to disease prevention and promoting healthy lifestyles. "This shift," the report states, "promotes maintenance of individuals at home and treatment in ambulatory settings. At the same time significant therapeutic and technological advances have led to increased complexity in caring for and treating individuals with a variety of health conditions."

Because of these changes, the health care labor market provides tremendous career choices for nurses outside the hospital setting. Outpatient facilities like The Emory Clinic definitely have an edge on the competition. "We have noticed the nursing shortage, but I feel we are still able to meet our needs because of the kind of environment we offer -- a Monday-through-Friday schedule with no nights or weekends," says Rick Springfield, who heads human resources for the clinic.

Wesley Woods Center and its large geriatric patient population provide another career alternative for nurses seeking a new environment and new challenges. But the center is facing its own recruitment dilemma.

Wesley Woods Geriatric Hospital faces the same recruitment challenges for RNs as other hospitals. However, Wesley Woods' long-term care programs at Budd Terrace and the A. G. Rhodes Home rely more heavily on licensed practical nurses (LPNs) and certified nursing assistants (CNAs). Other Atlanta hospitals now use LPNs and CNAs to save costs, so Wesley Woods has to compete for these individuals as well.

"That's a new phenomenon for us," says Larry Minnix, Wesley Woods president and CEO. "This has been a great place for LPNs and CNAs to work, but now I'm competing with hospitals which have stronger revenue streams than we do. That makes it difficult when you're trying to recruit and retain people to give continuity of care and compassion at the bedside. Recruitment can be particularly difficult for long-term care -- and now it is even harder."

"Geriatric nursing is difficult," he says, "because aging can't be cured. For nurses, the rewards are through relationships, not necessarily outcome. Wesley Woods has been particularly fortunate to have a number of RNs, CNAs, and LPNs committed to this mission."

The clinic's Springfield sees two dynamics at work in the nursing market. "One, nurses are looking for something less physically demanding than the high-acuity level within a hospital. Second, there are other opportunities for nurses besides direct patient contact. They can use their clinical training in areas such as reimbursement and precertification or outside the health care environment in insurance and legal consulting."

As an incentive, Springfield strives to offer competitive salaries to veteran nurses. "With the shortage comes the upper pressure on wages. One way to stay competitive is to factor in every bit of experience a nurse has."

Chris Coppinger, a nurse practitioner in gynecology at the clinic, has not felt the pinch directly since she works with outpatients and not in a hospital setting. But she has read about the shortage and has picked up on it from her colleagues in the hospital. "It's discouraging," she says. "It's important that patients receive the care that RNs are qualified to give."

Outside the box

Attracting and retaining experienced nurses requires creative measures, such as Emory Hospitals' CASH referral program.

Name: Kedra Phillips
Vital Stats: age 23; experience, one year
at EUH
Last seen: taking vitals -- general surgery
unit, EUH

Attracting and retaining qualified nurses definitely requires creative measures. Emory Hospitals' CASH program offers a $250 reward to employees who refer successful candidates for nursing jobs here (see www.emory.edu/HR/CASH.html). In 1999, CASH referrals resulted in 158 new hires, including 76 nurses and nursing technicians. Also last year, the hospitals began accepting job applications online, and recruiters see more nurses applying via the Internet.

The pool for nursing applicants extends nationwide and includes other academic health centers. Currently, Emory Hospitals are focusing their recruitment efforts in the Northeast and the Midwest, where hospitals have cut their staffs. Ads touting Emory Hospitals appear in specialty and nursing journals. Recruiters also work with local real estate offices to tap "trailing spouses" among couples relocating to the Atlanta area.

When West Paces Ferry Hospital closed in December, Emory Hospitals took an active role in the job fair hosted by Emory Healthcare. Four West Paces nurses were hired to help staff the new Care Initiation Unit in Emory Hospital in which new patients are started on lab tests and x-rays while their beds are readied.

Through these and other efforts, Emory Hospitals have fared well considering the 15% to 17% average national vacancy rate for nurses. "We run less than a 6% vacancy rate, which is very good," says Vautier. "We hire resource (temp) nurses to try to fill that.

"If you asked our staff, they would clearly say that we have also reduced staff through attrition as well as cost containment. But our numbers are still very good when they're compared nationally."

To help fill any nursing gaps, the hospitals use a method known as flexible budgeting based on hours per patient day. When the patient census goes up, the hospitals turn to nursing agencies to hire traveler nurses -- experienced professionals who work for 13 weeks. When the patient census dips, staffing drops back down.

But how do the hospitals ensure quality of patient care when nursing staff is in flux? Beside asking nurses to identify time-consuming tasks that don't add value to patient care, there are several options. One is to pay regular nurses to work overtime. Another is to use creative staffing, which allows nurses to work three 12-hours shifts and have an extra day off. Some nurses are cross-trained so they can fill in as temporary staff in another unit. As for traveler nurses, the Joint Commission on Accreditation of Health Care Organizations requires them to be highly qualified and meet patient care criteria.

Pam Cosper, department director for medical services at Crawford Long Hospital, uses traveler nurses in her units and understands why these young and experienced nurses prefer temporary work. They can work in different places at higher pay because they are willing to relocate frequently between hospitals and cities.

But Cosper prefers full-time nurses any day. "I want to hire people who have the same philosophy and commitment to high-quality patient care," she says.

Dangling carrots

Name: Shirley Eaton
Vital Stats: age 44; experience, 25 years
(ER at Piedmont; psychiatry at Brawner
Hospital and Wesley Woods); specialty:
Last seen: caring for the elderly -- Wesley

She is also a firm believer in using education as a retention tool. After joining Crawford Long as a staff nurse in 1987, Cosper took advantage of the courtesy scholarship program to earn her master's degree from Emory's nursing school. She encourages other nurses to do the same and keep pace with change through hospital continuing education programs.

"Everything changes so rapidly," Cosper says. "We have to learn to do things more efficiently and spend a lot of time on in-service education, computers, and documentation for clinical pathways (interdisciplinary care plans) to do our jobs better. We also have to communicate more clearly because we're working with more than one discipline. We're working with others as a team to accomplish patient care versus just one nurse doing it all."

Emory nursing leaders are equally adamant about training. Instead of offering sign-on bonuses, Emory Hospitals channel their resources elsewhere. "I feel pretty passionate about where we spend our money from a recruitment standpoint," Bloomquist. "We prefer to spend our dwindling dollars first on our own staff members by offering continuing education for experienced nurses and residency programs to attract graduate nurses"

Each year, the hospitals sponsor a series of daylong courses for experienced nurses in and outside of the Emory system. The programs serve a dual purpose: Emory nurses learn about the latest technology and advances in oncology, cardiac care, or perioperative nursing from clinical educators, nursing school faculty, physicians, and other experts. Nurses from other hospitals learn while checking out job opportunities at Emory or Crawford Long.

To attract new nursing graduates, the hospitals now offer residency programs in five areas: critical care, labor and delivery, emergency room care, oncology, and surgical services. New nurses agree to work for two years in return for three to nine months of training, depending on the specialty. Emory nurses with a few years of experience can also cross-train in another specialty.

Although training programs in surgery and critical care were already in place, "we found we needed to offer more," says Vautier. "So we enhanced the classroom learning experience so that staff can apply new knowledge to patient care in their areas."

Providing feedback on the job also helps staff learn and boosts morale. "It's important for nurses to know what's going right and what's going wrong," Cosper says. "We do surveys on patient satisfaction, and the patient comments mean the most to the staff. The nurses create memories that last a lifetime, and they're important to the healing process for the patient."

Lasting bonus

Name: Pam Cosper
Vital Stats: age 38; department director;
experience, 13 years at Crawford Long
Last seen: keeping pace with change --
medical services, CLH

For the long term, nursing leaders must continue to find ways to hire and keep good nurses. A large part of the answer lies in educating new nurses. NACNEP advocates the baccalaureate program as the best form of education to promote continuum of care, to adapt to rapid technological change, and to foster critical thinking and problem solving. Of the three education paths available to aspiring nurses - diploma, associate degree, and baccalaureate - the latter provides the most direct path to advanced training.

Projections through 2020 show that the supply of RNs will gradually increase but at a slower rate than the increase in the nation's population. Also, only 37% of the nursing graduates in 2020 will have baccalaureate degrees compared with the 59% expected to receive associate degrees.

Salmon explains: "When hospitals move into a massive shortage, the spigot that's turned up on the supply side is the two-year associate program because it's shorter. Such programs do not turn out the nurse who can provide a broader spectrum of services needed in today's health care system."

To help fill the pipeline with baccalaureate graduates, Emory Hospitals offers the Nursing Employment and Tuition Award (NEAT) program, which supports 40 junior and senior nursing students a year. As payback, new nurses work six months for each semester of tuition paid under the program after graduation.

"It really works for the students," says Vautier, who has seen 200 NEAT nurses employed by the hospitals in her 10 years here. "Not only have we paid 60% of their tuition, but we guarantee them a job in one of the most prestigious hospital systems in the country."

NEAT approach

Name: Scott Turner
Vital Stats: age 29; experience: senior nursing
Last seen: taking notes at Nell Hodgson
Woodruff School of Nursing

Another approach is to reach down to high school students and let them know what Emory offers in terms of health care education and employment after graduation. Recently, Emory Hospital staff mentored 13 Atlanta students from Washington High School as part of the university's Hughes Science Initiatives, a program to attract young minorities and women to careers in science. For three months, students spend four hours a week with a mentor in areas such as nursing, pharmacy, physical therapy, and social services.

These and other initiatives promise long-term dividends for patients everywhere. But heeding clear signs that the labor pool will continue to dry up, Emory leaders know they can't let up their efforts to train and attract nursing talent here.

"We must continue letting people know that Emory is the best place for nursing education and practice," Salmon concludes. "This is a wonderful place for nurses to train and to work. That's what we need to sell, and we need to be aggressive about it."

Pam Auchmutey is assistant director of health sciences publications and editor of Emory Nursing magazine.

In this Issue

From the Director  /  Letters

Through Thicket and Thin

Traveling Well

Wanted: More Good Nurses

Moving Forward  /  Noteworthy

Nurses' Prescriptive Authority

Trash or Treasure?


Copyright © Emory University, 2000. All Rights Reserved.
Send comments to the Editors.
Web version by Jaime Henriquez.