"$5,000 per week!! Nurses needed now!!" trumpets an ad in the November issue of AACN News, a magazine for critical-care nurses.
San Jacinto Methodist Hospital in Baytown, Texas, is offering a $3,000 sign-on bonus for cardiac-catheterization nurses amid the eight pages of nursing help-wanted ads in the Houston Chronicle. San Jacinto, however, is trumped by the Air Force, which is offering a $5,000 bonus on a neighboring page.
In San Jose, Calif., a nursing home is offering a $1,500 bonus for a certified nursing assistant. Meanwhile, on the East Coast, Staten Island University Hospital is advertising a $5,000 sign-on bonus in the New York Times for burn-unit nurses who stay a year.
An outfit described as "your neighborhood hospitals" is advertising a $5,000 sign-on bonus in the Houston paper for experienced operating room nurses-if they come to work at Chippenham Medical Center in Richmond, Va.
While Virginians go poaching in Texas, guess where Texans are recruiting? Canada.
It's coming to that point again. There aren't enough nurses for everybody who wants one.
Critics say hospitals, which are hurting the most in this shortage, have mainly themselves to blame. That segment of the industry is getting paid back for its stifling corporate cultures and lack of respect for nurses, the critics argue.
"There are enough things lining up in the environment that suggest a severe nursing shortage in the next 24 to 36 months," Geri Marullo, former executive director of the American Nurses Association, predicted a year ago. "I've been in the business long enough; this is the third time I've been through it. I'm feeling those symptoms again," she said.
You don't need to tell Virginia Frost about the shortage. She is assistant administrator for patient care at Northeast Medical Center Hospital in Humble, Texas, just outside Houston.
Frost is looking for neonatal intensive-care nurses and several other specialties. "Right now we are acutely short of medical-surgical nurses on the regular units. Our vacancy rate isn't that high, but I'm probably short one or two nurses on every shift."
Even the American Hospital Association is starting to hear about the shortage indirectly through its regional policy boards. "It's certain kinds of nurses in certain parts of the country, no pattern to it," says Richard Wade, the AHA's senior vice president for communications. What popped up most frequently are specialty nurses such as operating room, emergency and intensive care. "It's all anecdotal as of now," he says.
Worldwide problem. And those stories aren't limited to the U.S. Beverly Malone, president of the ANA, says numerous foreign countries are experiencing the same phenomenon. "We had (representatives from) seven countries here for a conference in August," she says. "The nursing shortage was at the top of the list." The only country that didn't have one was Japan.
Unfortunately, no conclusive data exist to describe what is happening. The hospital association is "in the early stages of trying to get some," Wade says. So far the AHA regions with shortages are California, the upper Midwest and the South, he says.
The most recent statistics published by the AHA show that 976,818 registered nurses work in U.S. hospitals.
While global statistics are few, a nurse recruiter's numbers may suggest what's happening. Allied Consulting, a staffing and consulting firm based in Dallas, used to earn its bread and butter searching for physical and occupational therapists and speech pathologists.
Now those have taken a back seat. Allied conducted seven nurse recruiting searches in 1996, 88 in 1997, and 193 so far in 1998. Of those 193, 41% were critical-care nurses, 21% were operating room, 12% were labor and delivery, and 4% were medical-surgical. The rest were spread across other specialties.
John Buffa, Allied's vice president, remarks that "subspecialty nurses are huge right now: pediatric, geriatric, oncology. In the advance-practice field, certified registered nurse anesthetists are in greatest demand." He conducted 12 of those searches last year, but he's done 47 so far this year.
"When major metropolitan areas start recruiting at this magnitude, looking not for a nurse but for 25 nurses," rural hospitals don't have a chance, Buffa says.
Helen Johnstone, manager of the orthopedic department at City Hospital in Martinsburg, W.Va., says she can't retain experienced nurses. She can hire people right out of nursing school, "but OB, telemetry, ICU and ER really prefer that the nurses they employ have at least two years' experience," she says. That's too bad, because after a couple years' experience those young nurses can shop for a better-paying job in a metropolitan area. She couldn't match the urban wages if she wanted to. Medicare reimburses her hospital less because it's in a rural area.
Starved in the West. Anecdotal reports generally emphasize the regional nature of the impending shortage. California, especially the northern part of the state, has been starved for nurses for more than a year. In fact, the shortage has forced leading systems, such as Mercy Healthcare Sacramento and Kaiser Permanente, to capitulate to labor contracts with nurses unions that have proved expensive to carry out.
The South Florida Hospital and Healthcare Association is hearing from its members that nurses at certain skill levels, such as intensive care or long-term care, are hard to find. It's also difficult to hire people willing to work certain shifts, such as nights and weekends. Linda Quick, the association's president, says: "There are plenty of people in town with nursing degrees. But we don't have them willing to work the salaries, schedules and settings that are available."
Nurses, in short, are becoming fussy about where they work, when they work and what they do when they're at work.
Malone highlights one of the ironies of this situation: The dearth of nurses is occurring mostly in hospitals.
"Usually, when we speak of shortages, we're speaking of the hospitals, because we can monitor them better," Malone says. "We can't measure all the nurses working in the community." Those settings are newer, more varied and harder to get a handle on.
They also tend to be the settings that nurses prefer to work in, given the choice.
Places to go. There are plenty of reasons nurses are in short supply. All involve change: structural changes in the field, changes in healthcare delivery, changes in education and changes in the psychology of nurses.
First, nurses now have opportunities that weren't even dreamed of a generation ago. They can work as nurse practitioners, as nurse anesthetists, critical-care nurses or neonatal intensive-care specialists, all of whom are in high demand. They can work for home health agencies, in nursing homes, as utilization-review nurses, as administrators, as teachers, as midwives, for managed-care plans, in doctors' offices or in day-surgery centers.
Or they can work in hospitals, where by general consensus, the work is hardest, the system most rigid and the hours most undesirable.
And this shortage isn't exactly a problem of supply, Malone says. It seems to be driven more by demand. The universe of applications of nursing skills has expanded so rapidly that experienced registered nurses are being drawn to higher levels of practice, leaving vacancies behind.
LDS Hospital in Salt Lake City, for example, has hired 70 registered nurses in the past eight months. Almost all have been new graduates. "We call them the rookies," says Donna Davidson, operations officer for nursing at LDS Hospital and three other Intermountain Health Care hospitals. "We're having to use agencies and travelers to fill our specialized needs: critical care, operating room, labor and delivery, emergency department, where (nursing) requires additional training and experience."
The demand is soaring in part because the acuity of patients is so high, Davidson says. Only those intensely ill are hospitalized, which puts a new burden on nurses. The mental and physical heavy lifting take a toll, especially on young people who have been shielded from the reality of the workload. As a result, Davidson says, her hospital loses a lot of recent graduates about three years after they start to work. "They leave to do something less demanding," she says.
Nurses are older now: The median age is 44, but about 10 years ago it was 38. And nurses just graduating tend to be older, so they have fewer years of professional practice ahead of them. Furthermore, fewer people are going to basic nursing school, while many experienced nurses are enrolling in master's programs to ascend to the specialty levels.
R-E-S-P-E-C-T. Representing a widespread opinion in the nursing community, Malone lays the blame for this problem largely at the hospitals' own door.
A few years ago, hospitals began cutting back on registered nurses based on the advice of consultants peddling "patient-centered care," which often was downsizing disguised as restructured care delivery. The hospitals tried to replace the nurses with unlicensed assisting personnel. But it didn't always work out as planned. Now some hospitals are revising the skill mix again to add registered nurses on patient floors.
"I do believe our colleagues in the industry-I mean hospital administrators-have awakened," Malone says. "Replacing our RNs with those who are less prepared is not always the way to go."
During the restructuring, hospitals retreated from hiring new graduates. If those new nurses had been brought on board, they would now be the experienced staff nurses hospitals are so desperate to find, Malone argues.
Well, too bad for the hospitals. "Nurses would rather work in places they feel valued," Malone says. "Some of the hospitals did not make nurses feel valued at all. When they let them go, they didn't feel like going back. Their skills are highly in demand in other settings."
And some nurses, like physicians, are just getting tired of the whole thing. In an article published in a 1996 issue of the American Journal of Nursing, Boston College researcher Judith Shindul-Rothschild wrote that 76% of nurses said they would remain in the field. That was a decline from 86% in a 1986 survey. "We had never seen such a precipitous drop," she says.
Enticements. Hospitals are taking a variety of measures to entice nurses. Frost, in Texas, employs a nurse recruiter. She works with the community college to make sure the nursing students take part of their training in her hospital. Recently, she added an incentive for incumbent employees. If an employee refers someone who is hired and stays at least six months, that employee gets $500 for the referral.
And she's gradually raising wages. "Since July, we have noticed that we continue to have to offer above the midpoint of the pay scale." The hospital has always shot for the 80th percentile in compensation. Now it has to bump it up a little bit, she says. "The whole market is moving up. We have to move up with the market."
Qualified, experienced applicants, when presented with a salary offer, are coming back with: " `Well, that's nice, but I can make more money someplace else.' And they can." The nurse recruiter then asks Frost for a little more money. She has to fork it over, because "they don't call back unless we call them back. That puts us in the hot seat. This is a business."
BJC Health System in St. Louis has set up a systemwide job hotline. Job hunters can dial (314) 863-JOBS and see what strikes their fancy. It's a more efficient way of reaching the inactive job seeker, who doesn't have a resume prepared, says Marty Lenihan, BJC's recruitment manager.
Recruiting on the Internet is also picking up. The BJC World Wide Web site lets people who prefer a computer to newspaper classifieds click on "employment opportunities."
Janet Desnoyer, director of professional development for BJC, maintains relationships with three local schools of nursing: Barnes College of Nursing, Jewish Hospital College of Nursing and Missouri Baptist College of Nursing. The schools are creating specialty tracks, such as intensive care and operating-room skills.
Desnoyer is seeing a more mature student body of people going back to school in their 20s, 30s and 40s, "sometimes because of displacement in other fields," she says. "People also see healthcare as a secure career. People are looking for more satisfaction in their careers and that humanitarian aspect they don't get from other occupations."
Go anywhere, get work. Shaun Elam, a former arts administrator, did just that. A recent University of Utah graduate with a bachelor of science degree in nursing, Elam is working at Davidson's LDS Hospital. And not just as a staff nurse. He's on a medical-surgical intensive-care unit and loving it.
"My co-workers were surprised to hear that I was a new grad," he says. "Two or three of my classmates went into critical care or ER right away. Those are traditionally not for graduates. They want experience."
He went into nursing because he didn't think he'd ever get bored or change careers again. He thought he could go anywhere and get work.
By the time he finished school, he was vaguely aware that nurses were in high demand again. He can't think of a single person in his class who didn't have a job waiting.
Of course he might not stick around forever in the ICU. He's thinking about going back to school. The idea of becoming a nurse anesthetist or nurse practitioner is mighty appealing, he says. "It just seems like everybody is clamoring."
