Testimony For the Subcommittee
on Appropriate Supply and Utilization of
Michigan's Health Care Workforce of the Standing Committee
on
Health Policy
Testimony on Nursing Shortage August 27, 2001
Patricia W. Underwood, Ph.D., RN
Michigan Nurses Association, Past President
Professor
Kirkhof School of Nursing
Grand Valley State University
Grand Rapids, MI
As a past president of the Michigan Nurses Association,
I am here to testify on behalf of the MNA and the more
than 80,000 registered nurses actively practicing in
Michigan. We commend the members of the of the Subcommittee
on Appropriate Supply and Utilization of Michigan's
Workforce for your initiative in seeking to understand
how we can maintain, increase, and appropriately utilize
our nursing workforce. As you are aware, nursing is
a profession that demands a high level of skill and
education to fulfill a critical role in meeting the
health care needs of a diverse population. Before we
consider strategies to achieve a sufficient supply
of well-prepared nurses, it is critical that we understand
the nature and dimensions of Michigan's nursing workforce
supply problem. Therefore, I will do three things today:
- present some facts that suggest that we are facing
a nursing workforce problem in Michigan
- clarify what we mean when we talk about a shortage
of nurses
- identify areas in which to focus our efforts to
address the supply of nurses in Michigan
Michigan Nursing Workforce
Unfortunately, in Michigan, we do not have an adequate
system of ongoing data collection sufficient to
yield reliable projections of our future supply of
nurses. This was one of the reasons that Public Act
256 was passed last year to mandate a study of the
nursing workforce supply. It is anticipated that the
Legislature will soon be receiving copies of the final
report from the Department of Consumer and Industry
Services. Formal and informal discussions have yielded
the following data:
- As of 1998-99 there were an estimated 106,195
nurses including 83,800 RNs and 22,395 LPNs actively
practicing in Michigan
- In informal discussions, many hospitals report
significant vacancies in nursing particularly in
critical care, emergency rooms, and other specialty
areas. One hospital administrator told me that she
could hire 200 registered nurses tomorrow if they
were available.
It does not bode well for the future that:
- While the Michigan population has increased by
.8%, the number of working RNs and LPNs has increased
only by .4%
- The number of graduates from LPN, ADN, and BSN
programs has generally declined throughout the state.
- National data indicates that the average age of
the working RN is 43.4 years
- Additionally, the average age of faculty is 55
years, so any attempts to increase the number of
graduates from nursing programs must begin with
efforts to recruit and develop more faculty.
The need and demand for nurses has increased in all
settings and is expected to continue. Although patients
are experiencing shorter stays in the hospital, the
only reason they are there to begin with is because
they need nursing care. The fact that they are sicker
means that more registered nurses are needed to make
the frequent checks and critical judgments that will
prevent complications. When Jim Brady lay in the Intensive
Care Unit after being shot in the attack on President
Reagan, he was lucky to have the care of an experienced
ICU nurse. Her experience made her concerned about
her patient's condition one night. She reported her
concerns to the physician who did not share them because
the patient's vital signs were not unexpected. Nevertheless,
the nurse remained vigilant. When a change in Brady's
condition became more evident, she knew immediately
and took the emergency steps that in fact saved his
life. He had experienced a blood clot in the lungs
that might have been fatal if it had not been treated
quickly.
It is not just a case needing more registered nurses.
We need nurses with the experience, education, and
expertise to anticipate and respond to patients' needs
in the most complex and novel situations. Studies have
shown that an inadequate supply of registered nurses
in the acute care setting is associated with increased
rates of hospital acquired infections, falls, and decubitus
ulcer formation. Lengths of stay increase, while patient
satisfaction decreases. These occurrences also increase
health care costs.
Inadequate staffing takes its toll on the nurses as
well. I have talked with staff nurses around the state.
They are frustrated by the significantly increased
demands that are placed on them in the workplace. Their
comments support the findings of national and international
studies that report increased rates of burnout (as
high as 36%) among nurses (Aiken et al., 2001). As
many as 40% of the nurses reported that they leave
aspects of care such as oral hygiene, skin care, patient
teaching, comfort and updating plans of care undone
when they leave, because they simply do not have time.
Nurses are sad that they cannot give the quality of
care they believe patients need and are worried that
fatigue and stress will lead to mistakes in care. In
another study of 7,300 nurses, 75% stated that they
believed the quality of care in their hospitals had
decreased in the past year (ANA, 2001). The Michigan
Nurses Association conducted a survey of nurses in
the Grand Rapids area last year and found similar results.
Increasing numbers of nurses face patient and family
complaints and verbal abuse (Aiken et al., 2001). In
view of the increase in work stress, decrease in job
satisfaction, and increase in verbal abuse, it is not
surprising that 29% of nurses under the age of 30 report
plans to leave their present job within the next year
(Aiken et al., 2001). Thus, it is obvious that a problem
exists, that the need for registered nurses will continue
to increase, and that Michigan is likely following
a path similar to the rest of the country.
Definition of Nursing Shortage
The supply of nurses in Michigan does not meet current
needs and, unless things change, will not meet future
needs. In order to find appropriate solutions to workforce
needs, it is important to understand that we are experiencing
two different shortages. The present shortage
is typical of the cyclical shortages that occur as
a result of reorganization in health care. Cut backs,
in the use of nurses, support the perception that job
openings are limited. The effect of this perception
is a decrease in the number of individuals who seek
preparation for licensure as a nurse. This cycle is
enhanced by the plethora of educational and professional
opportunities open to young people today. It is also
enhanced when stressed nurses do not encourage others
to join their profession. In the past, we have tried
to address this shortage but have failed to break the
cycle.
Along with our present shortage, we are facing a future
shortage that is unique, because it is a significant
projected deficit of more experienced and educated
nurses. It is a shortage that will not be amenable
to the simple infusion of new graduates into the professional
workforce. It is expected to arrive around 2010 as
substantial numbers of
faculty and nurses in direct care retire.
Focal Areas for Addressing the Shortage
Plans to address the nursing workforce in Michigan
must focus on both types of shortages. Thus, it becomes
evident that retaining nurses is as critical an issue
as the recruitment into the profession. So where should
we focus our efforts at solution? Quick fix strategies
such as mandated overtime or the infusion of undereducated
and quickly trained assistive personnel are not
the answers. None of us would choose to fly in
a plane where the pilot was unduly fatigued. Nurses
make equally critical life and death decisions; and,
therefore, should be equally rested. Likewise, none
of us would willingly put the care of our family members
in the hands of an individual who three weeks ago was
flipping burgers. We want well-educated professionals
available to make the critical checks and judgments
needed to prevent complications and facilitate optimal
health and wellbeing. If we are going to find a lasting,
comprehensive solution to both nursing shortages, all
of us: nurses, legislators, administrators, educators,
physicians, other health care providers, payers, corporations,
the media, and the public are all going to have to
work together. There are several places we can start:
- Develop a center for the routine collection
of Michigan nursing workforce data to more adequately
describe the current reality and project future
nursing workforce needs, availability of clinical
resources, graduation rates, etc.
- Support studies of new models of nursing care
delivery in areas where our need is most critical.
We need to see what levels of staffing and staff
mix are necessary to achieve desired patient outcomes
in a cost-effective way. Such studies should include
the collection of nursing sensitive quality care
data.
- Encourage the implementation of best practices
to more effectively retain nurses, even as they
age with the rest of the population, and to support
them in providing quality, nursing care. We know
through a study of magnet hospitals, for example,
that good communication between doctors and nurses
and giving nurses more decision-making authority
at the bedside and throughout the organization greatly
enhances retention (Sochalski & Aiken, 1999).
Decreasing stress in the workplace is an essential
first step, but other strategies such as improved
pay and providing retirement benefits are important
in keeping nurses at the bedside.
- Encourage and support a state-wide collaborative
initiative aimed at further clarifying those
aspects of the shortage of nurses in Michigan that
are most amenable to lasting solutions. Through
this collaboration we can develop creative strategies
to address these areas and support their implementation.
It will do absolutely no good if comprehensive reports
and recommendations are developed only to languish
on someone's shelf.
Conclusion
In conclusion, we should all recognize and help others
to understand that when we talk about a shortage of
nurses in Michigan, it is very real and we are talking
about two shortages: a typical shortage that we are
currently experiencing and a potentially devastating
shortage that is barreling down on us. The second will
occur as the result of the loss of our most experienced
and educated nurses. Since the average age of nurse
educators is 55, schools of nursing will potentially
feel the shortage of faculty first. This may further
constrain our ability to increase the numbers of qualified
graduates needed in nursing service. While Michigan
data are limited, they support a clear need for more
registered nurses. Lasting solutions to the nursing
shortage will only be developed through our collaborative
efforts focused on:
- Enhancing the image of nursing as a valued, rewarding,
and appropriately compensated career.
- Recruitment of a more diverse population of academically
talented individuals
- Support for students' success in completing programs
of initial professional education, obtaining licensure,
and going on for advanced education.
- Maximization of the capacity of existing educational
programs in producing well-prepared graduates.
- Encouraging nurses to obtain further education
and prepare for roles as faculty.
- Increasing the ability of employers to attract
nurses to settings (geographic and clinical) where
the needs are most critical
- Retention of a qualified and satisfied workforce.
In Michigan, the nursing shortage is here, and
nurses welcome the partnership of legislators in addressing
this issue so that the people of Michigan will continue
to receive quality nursing care.
References:
Aiken, L. et al. (2001). Nurses' reports of hospital
quality of care and working conditions in five countries.
Health Affairs, 20, (May-June).
American Nurses Association. (2001). Analysis of American
Nurses Association Staffing Survey. Warick, RI: Cornerstone
Communications Group.
Sochalski, J. & Aiken, L. (1999). Accounting for
variation in hospital outcomes: A cross-national study.
Health Affairs, 18, 256-259.
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