Registered nurses have raised their voices long and loud on the subject of patient-care restructuring in U.S. hospitals.
Lost in the din, though, are some relevant facts that help explain why hospitals feel compelled to shift employment away from registered nurses and toward less-skilled personnel, and even higher-skilled nursing.
They may not like to talk about it, but the truth is, nurses are doing very well, thank you. According to a study published in January by the Institute of Medicine, a Washington-based government advisory group, they have prospered mightily over the past 12 years, in large part because of efforts to remedy a nursing shortage in the 1980s.
In a period when wages of many working people have declined in real terms, nurses' salaries have jumped.
In a period of great economic stress, covering two recessions, they have been insulated from unemployment.
In a period when whole economic sectors have shrunk, they have seen their employment prospects grow and their venues of employment multiply.
Statistics in the IOM report, Nursing Staff in Hospitals and Nursing Homes: Is it Adequate?, show that between 1983 and 1993, the absolute numbers of employed registered nurses surged to 1.9 million from 1.3 million, a 47% increase. The United States added enough nurses in 10 years to populate Boston. In 1992 there were 2.2 million people with nursing licenses.
In relative terms, the story is much the same. By 1993 the country had 755 nurses per 100,000 people, compared with 292 per 100,000 in 1960-a two-and-a-half-fold increase.
The ratio of registered nurse full-time-equivalents per 100 adjusted average daily census rose to 106 in 1993 from 81 in 1983.
This professional growth continued even into the era of aggressive hospital restructuring. Full-time-equivalent nursing personnel in community hospitals rose 2.7% from March 1994 to March 1995, including an increase of 3.5% for registered nurses.
While registered nursing was growing, the ranks of licensed practical nurses in hospitals was declining almost 10%, to 262,238 in 1994 from 290,780 in 1988, according to the Bureau of Labor Statistics. Nurse assistant positions grew much more slowly in hospitals, by 5.5%, to 306,009. During these six years, the number of hospital registered nurses bounded 15.7%.
Unemployment for registered nurses, meanwhile, hovered below 2% from 1983 to 1994, while unemployment for all occupations was 5% and more. In other words, almost any nurse who wanted a job could find one.
But it is in income where nurses have pulled ahead most dramatically. In 1983, registered nurses made on average $396 a week, 26% more than the $313 earned by the average U.S. worker. By 1993, that gap had widened to $682 for nurses vs. $467 for everybody else-a 46% premium for nurses.
Salaries jumped most notably from 1988 to 1990, the period of the nursing shortage, when hospitals had to compete to attract nurses.
"Labor costs account for a major proportion of hospital costs," the IOM study notes. "Increasing salary levels, combined with the increasing size of the RN work force, have made RN employment a large and expensive cost center in the healthcare system. It would not be surprising then*.*.*.*if RNs have become a target for cost-cutting."
Nurses have been targeted most visibly in those markets where labor costs are high and managed care has penetrated most deeply, such as California. At Alta Bates Medical Center in Berkeley, for instance, the California Nurses Association, a militant union that recently split from the American Nurses Association, has tried to turn patient-care restructuring into a cause celebre.
But the nursing contract between Alta Bates and the CNA makes clear why the hospital feels it has no choice but to redesign the workload around fewer registered nurses per unit.
A staff nurse II after 10 years working full-time days earns $28.88 an hour, or $60,072 a year. That same nurse working full-time nights makes $34.14 an hour, or $71,009 a year. That does not include benefits, overtime or holiday shifts.
A staff nurse III after 15 years who works fewer than 20 hours is paid $44.62 an hour on the night shift. Annualized, that would be $92,822. Such nurses do not get benefits.
In the future, registered nurses will do the higher-level tasks for which they have been trained. "We just can't afford any longer to have registered nurses pushing discharged patients in wheelchairs to the curb. A less-trained, less-expensive person can do that," said Ruth Robinson, Alta Bates' vice president for human resources.
The IOM study predicts it is unlikely that the nursing profession's economic success can be sustained at this level. "Nursing has long ignored the obvious point made by economists that high salaries and continued high growth in new jobs are not compatible trends of the long run," the study says, quoting L.H. Aiken and M.E. Salmon.
Actually, there are indications that salaries are coming down. In 1994, registered nurses' earnings declined $5 a week, from their peak of $687 in 1993. Statistics for 1995 are not yet available, but they could show that hospital employment for registered nurses has started to slide.
"Nursing has traditionally always had full employment generally in hospitals," said Carolyne Davis, chair of the IOM committee. "There is always going to be a job for a nurse," but now the growth prospects have migrated into home care, ambulatory surgery and HMO clinics.
"But since they were educated to think they were going to work in inpatient hospital settings, it's a severe wrench in their thinking process," Davis said.
The report notes that "nurses with less training are losing positions in the inpatient hospital sector to nurse assistants and other ancillary nursing personnel, while those with advanced training may be able to find new opportunities."
The IOM committee says the nursing profession must move up the skill ladder if it wants to maintain its gains and ensure job security. More nurses are needed who have clinical abilities and who can delegate to and supervise less-trained caregivers. The richest opportunities may lie in advanced practice areas.
At the same time, lower-paid personnel such as licensed practical nurses and nurse assistants, need to be trained to take over some of the tasks for which registered nurses have become too expensive.
Copies of the IOM study may be ordered at 800-624-6242.