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July 11, 2002

Pitt, UPMC take action to address 'unprecedented' shortage of nurses

Pitt, UPMC take steps to address 'unprecedented' nursing shortage

The United States faces an unprecedented nursing shortage that's likely to get much worse, recent hospital surveys and news reports indicate. The supply of nurses — 2.4 million nationwide — falls well short of the current demand, resulting in 120,000 vacancies. That's projected to rise to upwards of 500,000 in the decade ahead.

Reports of hospitals delaying non-critical surgeries, a shortage in specialty areas such as nursing anesthesiology and the diversion of emergency room patients to other health care settings — coupled with a national decline in nursing school enrollments and a shortage of nursing educators — are symptomatic of a health care industry-wide problem.

Nursing schools, including Pitt's, are limiting enrollments in certain specialty areas due to insufficient nursing faculty.

Hospital recruiters, including those at UPMC Health System, are offering high salaries and benefits to new nursing graduates, even ones with little or no clinical experience.

UPMC and Pitt officials agree that there are no quick fixes to the nursing shortage.

Nursing employment tends to be cyclical. But the current situation is more acute for several reasons, according to Gayle R. Whitman, associate professor and director of the Center for Healthcare Outcomes at Pitt's School of Nursing.

"I sometimes facetiously say, 'I personally created a nursing shortage three times, but I've cured it at least four times,'" said Whitman, who previously served as vice chair for patient care operations at a Cleveland hospital. There, she was responsible for hiring about 400 nurses annually due to turnover on a nursing staff of 2,500.

"In my 25 years in nursing I've seen the cycle go up and down," she said. "In the past, if we just increased the number of people who went into the nursing programs and offered cash and other incentives like higher salaries to nurses, we could fill most of the needs. When the shortages were plugged, we just stopped the sign-up bonuses and salaries leveled off. But the shortage we're anticipating in the near future is so significant that that [strategy] alone will not work."

Contributing factors Among the factors contributing to the current nursing shortage, according to Whitman, are:

* More opportunities for women (who still make up about 94 percent of the total pool of nurses) to pursue careers other than nursing, and for current nurses to pursue non-nursing careers.

* Baby boomers reaching the age when they will need more health care.

* Technology and pharmacology advances leading to longer lifespans.

* The increased severity of illness of hospitalized patients, forcing a need for more nurses per patient and better-educated and specialized nurses in the hospital setting. (About 60 percent of all employed nurses work in hospitals.)

* Nurses' dissatisfaction with hospital working conditions.

* The effects, including some unanticipated ones, of the managed care environment.

"One effect of managed care is you don't keep the patient in the hospital if you can avoid it," Whitman said. "Hospitals are filled now with only the sickest people. So now you not only need more nurses per patient, you need nurses who are prepared at a higher level to deal with the sickest patients."

Whitman said that two unanticipated effects of managed care are influencing the nursing shortage in hospitals.

"The conventional wisdom was that once you start to control things under managed care, you'll probably have fewer patients in the hospital and hospitals would close. But hospitals are not closing at the rate we thought," as an aging population increases the rate of serious illnesses (also called "patient acuity").

Second, the effect of patient acuity rates on the mix of nursing personnel was underestimated.

"There was a belief that we could change the mix of nursing care at the bedside. Instead of having every nurse in every hospital unit being an R.N., maybe you could have 80 percent R.N.s, 20 percent technicians/aides, or maybe even 50 percent R.N.s, 50 percent technicians or aides," Whitman said.

"Some places tried that. What we learned is with patient acuity, we can't change the skill mix as aggressively as we thought without sacrificing patient care."

Most new nursing school graduates will take their first job in a hospital, partly because much of their training is in that setting, Whitman said. "What we want is our best and brightest nurses taking care of the sickest patients, but on a fairly typical career trajectory the bedside is only their first stop," she said.

After perhaps two or three years of experience, nurses will pursue other opportunities, including leaving the field, returning for an advanced degree, or going into another area of nursing — such as home-health nursing, public or community setting nursing, ambulatory care or nursing homes — where work schedules are more regular and pay is at least comparable.

Pressure on

hospital recruitment According to Gail A. Wolf, senior vice president and chief nursing officer for UPMC Health System, recruiting nurses for hospital jobs during this shortage is a major challenge.

"Short term, all you can really do is fight for the existing market, and that's what hospitals are doing," Wolf said. "They're positioning themselves to aggressively go after the current market of nurses."

Wolf pointed out that there are three ways to qualify for taking state nursing boards in Pennsylvania: earning a two-year nursing degree at a community college; graduating from a two-year hospital-based school of nursing, called a diploma school (there are two diploma schools in the UPMC system, one at UPMC Shadyside and one at UPMC St. Margaret's), and graduating from a four-year college or university such as Pitt.

"Obviously, we'd like all [UPMC nursing new hires] to be university graduates," Wolf said. "But many of them, financially, cannot afford that. So, they will go through a two-year, hospital-based school, qualify for taking their boards, [join the UPMC staff] and then take advantage of our tuition reimbursement program and go on for their baccalaureate."

In addition to tuition reimbursement, the health system has initiated other programs to help recruitment and retention, she said. "We've put in a clinical advancement and promotion program so that, as nurses demonstrate greater skills and are able to perform better, we're able to compensate them better."

The program, which rewards nurses for staying on staff, enables nurses to earn up to $80,000 by staying in the clinical setting.

In addition, "We've done major marketing campaigns, we've done recruitment fairs, we've done all of the typical things you would think of with regard to recruiting nurses," Wolf said.

The nursing school's Whitman added that hospitals must be ready when graduates become available or risk losing them to other hospitals.

"It's like the NFL draft: You get a chance at them one time a year," Whitman said. "Nurses typically graduate in April and if I want to hire someone in November, it's a lot harder. So hospitals have to get in sync with the graduation cycle. Even if you wait until July in a hospital in Pittsburgh, I can guarantee you our [Pitt's School of Nursing] students are gone; they're already placed. That may mean you occasionally double-hire, and temporarily you have too many people, but that's easier to deal with than a shortage. Hospital administrators can get burned if they aren't astute."

Whitman said that hospitals during the current shortage face additional internal pressures when turnover is high.

"If you leave today and give me two weeks' notice, it could take me anywhere from one week to three months to fill your spot, and then it probably takes me another 30, 60, or 90 days to orient you. That puts more pressure on the nurses on staff who need to fill in while your spot is vacant. To orient a highly specialized nurse, like an operating room nurse, it can take up to a year to get to where they're truly functioning independently at the job."

Because of those conditions, hospitals must occasionally hire nurses from national nursing agencies. Agency nurses will come as temps to fill vacancies — for a price. "It's a fine line to walk, though, because the regular staff knows that these [agency] nurses are working for much higher pay doing the same job. There's a resentment factor. Administrators have to know when to bring them in and when to let them go."

Wolf said UPMC is thinking long-term in its recruiting by offering various incentive programs to Pitt nursing students. One is the clinical scholars program, in which a clinical nurse mentors a senior nursing student. The student accompanies the nurse on the job for 36 hours a week, getting a hands-on feel for the work. UPMC even offsets a portion of the student's Pitt tuition.

Until now, the program has been offered to all Pitt nursing school seniors willing to work at UPMC Presbyterian, Wolf said, but UPMC is expanding it to several other hospitals as well.

"Other nursing schools have asked us to offer this program to their students, but so far we've stuck with just Pitt," Wolf said. "For us, the 'win' is that these students get to know our nurses, they get to know our hospitals, and it makes the transition [to working for UPMC after graduation] easier."

Incentive programs for Pitt students has had a tangible effect. According to Jacqueline Lever, executive director of Student Services at Pitt's nursing school, 49 percent of last year's B.S.N. graduates stayed in the area, most of them at UPMC hospitals. "Only six or seven years ago, that figure was more like 15 percent," Lever said.

Also during the last year, UPMC has offered a lump sum payment toward tuition and loans, in exchange for a student's commitment to work at UPMC for two years following graduation.

"We've said to our employees, 'We will send your spouse or children to Pitt or community college and pay half of their tuition," Wolf said.

UPMC is reaching into the potential workforce at even earlier stages, Wolf said. The health system has launched a high school initiative through its professional practice council at each UPMC hospital.

Every school in Allegheny County — and some beyond the county — has been 'adopted' by one of the UPMC professional practice councils, Wolf said. "Since October of last year, we have been in front of more than 10,000 high school students, faculty and guidance counselors talking about careers in nursing, specifically, and health care in general," she said.

UPMC nurses have been going out to the community on their own time, talking about their profession to high schools, junior highs and elementary schools, Wolf said. The health system also is sponsoring a nursing camp this summer.

–Peter Hart & Bruce Steele

(Part 2 will cover the implications of the nursing shortage for Pitt's School of Nursing. It will be published in the July 25 University Times.)

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