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Nursing shortage pinching Utah

Demographics put state at special risk

If in coming years you find yourself headed for the hospital, you might want to consider taking along a nurse to care for you.

The nursing shortage is already severe. National estimates say the United States will be 434,000 nurses short before 2020. And the pinch in Utah is among the worst.

Utah's population is high in the very young and very old — the two populations most likely to require medical services and, thus, skilled nurses.

The Utah Nurses Association this year cited a shortage of 2,000 nurses, with numbers climbing. Utah's is the third-most severe shortage in the country, with 592 nurses per 100,000 people, said Mindy deHoll, president of Advanced Nursing Service, which provides temporary nurses to fill critical gaps at local hospitals.

Debbie Mason, a registered nurse for more than 20 years, has watched her profession change, not always for the better. She knows firsthand that hospitalized patients require more care than they used to. Because of pressure to cut costs, only the very ill remain hospitalized; the rest are sent home as soon as possible — or never admitted.

"I have had a number of nurses in administrative roles harp about how when they were a nurse on the floor, they were in charge of 30-plus patients. What I tell them is that it has changed! The patients in their day that were the regular floor patients are outpatients now. Their ICU patients are our regular patients. Our ICU patients were dead in their day."

"The nursing shortage definitely shows up in the hospital," said Kim Wirthlin, vice president of health care at the University of Utah. "On a daily basis, hospitals throughout the state have nurse vacancies. To ensure that patient care is not compromised, hospitals fill those vacancies by paying overtime and using agency and traveling nurses. All very expensive solutions.

"If hospitals can't get the nurses they need, they close beds. Closing beds has an impact on patient access," she said.

The nursing crisis has come forcibly to the attention of the State Board of Regents, which oversees the state institutions where most nurse training takes place. The regents are promoting a $2 million special request to the Legislature to help increase the flow of new nurses, though it likely faces an uphill battle, with state revenues themselves in a critical state of health.

Pamela Atkinson, vice chairwoman of regents and a former Intermountain Health Care executive, emphasized the importance of the initiative during a recent regents meeting. "The need was acute, now it's critical. . . . The profession won't rebound without help. The shortage is affecting patient outcomes. We're talking life and death here."

National studies blame the shortage on several factors: Baby boomers are aging and require more medical care. And the "echo" of the boom has swelled the ranks of upcoming age groups. Nurses are aging, too. Fewer than 10 percent of the total RN work force are under age 30, says the American Association of Colleges of Nursing. In Utah, the average registered nurse is between 45 and 50.

Those factors come into play as nursing school enrollment and graduation rates are dropping.

Who will teach them?

Since 1995, nursing bachelor-level graduate rates have fallen 23 percent while associate-level graduate rates have dropped by nearly a third, National League for Nursing statistics show. Though it seems logical simply to recruit more students, it's nearly impossible without hiring more instructors.

But fewer nurses are interested in teaching, and if nursing schools had the additional faculty, they'd still have to find a way to cover the other costs of training more students. National accrediting agencies set standards; there's no possibility of stinting or overloading classes.

Utah has a dubious advantage in the fact that there are more applicants for nursing spots than can be accommodated. In some states, educators are begging for students.

Six state colleges and universities manage, in total, to graduate 571 new registered nurses each year, said Rick Kinnersley, president of the Utah Hospitals and Health Systems Association. Between Westminster College and Brigham Young University, another 139 graduate each year. The University of Phoenix also has a very active nursing program. Combined, it's not enough.

The Legislature is being asked for $6.5 million to pay for schooling of 489 additional RNs, which would bring the total to just over 1,000. The regents included $2 million in their budget request, but the whole $6.5 million is needed to nearly double the number of nursing graduates. That won't fill existing vacancies, much less expected holes. Kinnersley said most of the money would increase faculty numbers and salaries.

Weber State College President Ann Millner said her nursing school would be ready to graduate 250 bachelor-level students each year, "if we could get adequate faculty."

At every level of the training chain, the lament is the same.

Hire a nurse, save a life

The Joint Commission on Accreditation of Healthcare Organizations in August found nurse staffing levels have been a factor in 24 percent of the 1,609 unanticipated patient events that resulted in death, injury or permanent loss of function over the past five years.

A recent article in the Journal of the American Medical Association said that adequate staffing of registered nurses saves lives. Conversely, overloading nurses causes serious problems.

In the study, each patient added to a registered nurse's workload was associated with a 7 percent increase in the likelihood of death within a month from a complication acquired during hospitalization. Each added patient was also linked to a 23 percent increase in the odds of nurse burnout and a 15 percent increase in job dissatisfaction.

"Patient care suffers, without a doubt," said deHoll. "That's a reality our community needs to realize.

"A nurse's job is far more than giving a bath. If they don't see things coming and identify what's happening to the patient, the doctor will never know. You go to a hospital to receive a nurse's care and to a doctor's office to see a doctor."

The Joint Commission also found that 90 percent of all long-term care organizations nationally lack sufficient nursing staff to provide even basic care. The figure is higher in Utah.

The New England Journal of Medicine said that care provided by registered nurses resulted in fewer cases of pneumonia, shock or cardiac arrest, upper gastrointestinal bleeding, sepsis and deep-venous thrombosis.

No outcome benefit was documented with care provided by licensed practical nurses or aides. That doesn't mean they're not important to patient care. But the more advanced care is provided by registered nurses. And experience counts a lot, deHoll said. Hospitals need new nurses, but they absolutely crave experienced nurses.

Janiel Wright, head of the medical/surgical unit at Lakeview Hospital in Bountiful, sums up the shortage this way: "Things go in spurts. Right now, we are OK, but we are always concerned. We need a constant flow of new nurses."

High-burnout areas

Various units in the hospital have different needs and recruiting problems, she said. The high-stress care areas such as labor/delivery and critical care units tend to have greater demands, as well as more evidence of burnout.

The twin problems of nursing are getting enough trainees into the pipeline and keeping those who are trained. "Once they're in the profession, they don't stay," Wright said.

She's been there, done that. After six years in the University Hospital neurology critical care and emergency room areas, she opted for the less-stressful small hospital atmosphere. Many nurses simply opt out.

The result has been a new breed of nurse, what deHoll calls "appliance nurses," typically women who have chosen to stay home with their children. When they need a little extra money — it's time for a new fridge — they work some shifts to pay for it.

Many nurses also choose to work for agencies, assigned to different facilities as temporary staff. They can pick how many hours they work and which ones. "A nurse working for us may not need benefits but wants a better wage package. We offer more flexibility. And a lot of nurses don't want to work the same place day in and day out. There are too many politics, institutional hoop-jumping."

Without temporary staff, most hospitals would be hard-pressed to meet patient need during busy times.

Luring them back

Area hospitals are going all out to draw back nurses who have retired or left the work force, Kinnersley said. They're looking at wages and trying to simplify the process so that the nurses would not need "all the relicensing exams unless they've been gone for a really long period of time."

University Hospital is among those putting great effort into retaining the nurses it has, said Rick Fullmer, chief executive officer. It's also providing $500,000 to the College of Nursing for tuition grants for hospital employees who want to get into or return to nursing or for new students who would agree to work at U. Hospital for two years. They also provide flexible schedules and career tracks that match the nurses' goals; someone who wants to work AirMed can build the needed skills in medical surgery, then critical care, followed by the emergency department, said Jadie Berry, chief nursing officer.

While competitive pay is crucial, "it's not all about money," Fullmer said. As important is working environment. Berry and Fullmer hold regular "town meetings" with nurses.

There's a "no-temper-tantrum" policy to ease doctor/nurse relationships. "We have policies, and a physician can be reprimanded for inappropriate behavior," Fullmer said. "It's a human kindness sort of issue, and it goes a long way. We don't allow outbursts, throwing things across the room. Nurses feel like the administration is behind them."

Statewide, hospitals have been contributing what they can to boost the number of nurses being trained. And they're working together to lobby the Legislature for funding.

High-pressure recruiting

Cooperative in that effort, they're fierce competitors when it comes to recruiting. For instance, St. Mark's Hospital and Mountain View in Tooele have at times offered a $5,000 sign-on bonus. The U. Hospital offers a bonus to employees who get nurse friends and acquaintances to join the team. Some, like the VA, will pay back or forgive student loans. Others offer education incentives or a combination of benefits.

Rural hospitals may be hardest hit by the shortage because they don't have the facilities to develop new nurses and offer continuing education. In winter, nurses don't want to drive a long way to school. (The Internet helps there as some programs, like the University of Phoenix, offer many class opportunities on the Web.) And rural hospitals have a harder time offering clinical training.

Lakeview is doing a lot to retain its nurses, Wright said, including some hiring bonuses. "Hiring bonuses are questionable. They get nurses in the door, but they don't keep them. Retention bonuses are better."

The hospital tries to create units that are friendly and supportive, to offer competitive salaries and salary differentials for those who work off-hours. "We have no mandatory overtime — yet."

While 60 percent of all working RNs are employed by hospitals, the pinch is felt in clinics and doctors' offices, too.

Norma Larsen, a nurse in the pediatric unit of IHC's Memorial Clinic in the Sugar House area, said the most nerve-wracking problem at the clinic is lack of adequate backup. Their substitute "pool" consists of one other person.

It's an exhausting profession, Wright said, and many frustrations are not directly related to patient care. "When we come to work, we want to do a good job. But then there's charting, a huge responsibility that takes us away from patients. And families can be so demanding. They need to be educated about the realities. Sometimes they fail to recognize that we have more than one patient and all the paperwork that goes with each one. We tend to get discouraged as the demands pile up on us."

Even so, she said, "I'm proud to be in the profession. It's a great way to spend your life."