The phone often rings off the hook in the office of Poudre Valley Health System's resource services director. That's because the Fort Collins, Colo., healthcare network has a nurse vacancy rate of just 7% at a time when the national vacancy rate hovers around 11% and some hospitals see rates as high as 20%.
Not-for-profit Poudre Valley has circumnavigated the shortage that has so acutely affected Denver and much of Colorado. With a total of 800 nurses, the system last week had only 30 open positions, a vacancy rate it considers manageable.
In May of last year, 235-bed Poudre Valley Hospital earned the designation of "magnet hospital" from the Credentialing Center of the American Nurses Association, which confers that label on healthcare organizations that have proven to provide superior nursing care and an outstanding work environment for nurses.
Since earning its magnet status, of which 38 other hospitals also boast, Poudre Valley has cut its vacancy rate to 7% to 9% from a high of 20%. "I get calls two to three times a week from people wanting to know the process, to know how we did it," says Donna Poduska, Poudre Valley's director of resource services.
Poudre Valley is one of the healthcare systems in the country bringing creative new approaches to the problem of having an insufficient number of qualified nurses. By giving nurses a louder voice in clinical decisions and improving their work environment, these systems are steering around nurse staff shortages that have challenged hospitals in every state.
Struggling for solutions
In Colorado, Poudre Valley is an anomaly. About 100 miles south of Fort Collins, the demand this summer for staffed hospital beds in Denver outpaced supply 20% of the time at Exempla Healthcare's two city hospitals. The situation has since stabilized, but Exempla Chief Executive Officer Jeff Selberg is concerned that when flu season sets in, his hospitals once again will be forced to divert patients elsewhere.
Colorado's long-term-care setting is struggling, too. The turnover rate among certified nurse aides in the state is a staggering 99%, compared with a still-daunting national average of 72%, according to the State Board of Nursing. In Colorado, "pain from the shortage is universal," says the board's Program Administrator Patricia Uris.
Nursing shortages are not new-in the late 1980s hospitals weathered a shortage arguably worse than the one developing now. But the situation in Colorado is just one example of the fiercely rocky landscape hospitals now traverse to recruit and retain nurses. Across the country, acute-care hospitals-as well as outpatient and long-term-care facilities-face growing staff shortages, and nurse vacancies are what worry them most.
Hospitals have attempted various solutions to the problem-hefty signing bonuses, performance-based pay raises, flexible schedules and tuition reimbursement programs. In many cases, such efforts have helped attract nurses who might otherwise opt for less strenuous and more lucrative professions.
Without a coordinated approach to the shortage, nursing experts say, hospitals have been left in the difficult and often expensive position of relying on traveling and temporary nurses, or worse yet shuttering units that cannot be staffed with proper attention to patient safety.
"Whatever we do to solve this problem, we need to continue it instead of doing it while there's a shortage and then stopping," says Cathy Allman, vice president of nursing and healthcare professions for the Florida Hospital Association. With the highest percentage of elderly of any state in the country, Florida ranks 31st in the number of registered nurses per 100,000 population, according to the FHA.
Reconstructive surgery needed
Allman and many of her colleagues claim that until the nursing profession undergoes reconstructive surgery to beautify its image and acknowledge the critical role its practitioners play in delivering care, the shortage will continue to grow unchecked.
"Nurses are often still seen as the handmaiden of the physician," Allman says. "They are intelligent, critical thinkers and problem solvers who are actually the colleagues of the physician."
Hospitals that recognize nurses as more than physician aides-by giving them a voice in clinical decisions and listening to their advice regarding workplace-improvement initiatives-have not necessarily averted the shortage but do seem to have an easier time keeping the nurses they have.
As some hospitals work to attract new nurses by improving working conditions, others are participating in state and local groups to address the problem on a broad basis. These groups bring together lobbyists, educators, providers and nurses to get more students into nursing school and keep them in the profession once they graduate.
According to figures released early this month in the American Federation of Teachers' State of the Healthcare Workforce report, the nation's healthcare providers will need more than 450,000 additional registered nurses from 1998 to 2008. Last year, according to the report, 17,000 fewer nurses were working than in the previous year. The healthcare industry employed roughly 2.1 million nurses last year, not many more than the nearly 2 million it employed in 1996.
Meanwhile, the report says, the number of college students with plans to pursue a nursing career has fallen to its lowest level in 34 years, and enrollment in nursing programs has dropped dramatically over the past five years. Compounding the problem, fewer nurses who start school eventually graduate, according to the report.
Statistics quantifying the extent of the nursing shortage have been the subject of debate. In July, a General Accounting Office report said a nursing shortage could be on its way, but another study just two months earlier by the Congressional Research Service couldn't state conclusively that an across-the-board shortage of registered nurses existed.
At the least, hospitals across the country report anecdotal-and in some cases severe-difficulty finding and keeping nurses. The nurse vacancy rate at Geisinger Health System in Danville, Pa., for example, is 13%, "which is high for us," says Susan Hallick, the three-hospital system's senior vice president and chief nursing officer. Geisinger's rate compares with a national nurse vacancy rate of roughly 11%-representing about 126,00 nurses-the American Hospital Association's most recent figures show.
Letting nurses be heard
At Poudre Valley Health System in the college community of Fort Collins, as vacancy and turnover rates have improved, costs have fallen, too. "When we compare our nursing costs to other hospitals in the state, we're one of the lowest," Poduska says.
During the day in its medical/surgical units, Poudre Valley requires a ratio of one nurse to every three patients. Although such ratios are controversial-a first-of-its-kind law mandating ratios has sparked a firestorm in California-Poduska argues that because Poudre Valley nurses are responsible for fewer patients and work under less-stressful conditions, they tend to stay in their jobs longer and help foster shorter lengths of stay, better outcomes and fewer patient falls and complications.
For Poudre Valley, the most important part of creating that environment is giving nurses the chance to be heard. With clinical staff on all Poudre Valley's hospital committees, Poduska says, nurses "have input into the decisions that affect them."
Other magnet hospitals report similar successes, and all those contacted by Modern Healthcare cited empowered nurses as a main reason.
"These magnet hospitals don't have a shortage, and one of the key factors that has been identified as a cause is that RNs have decisionmaking authority from the bedside all the way up through the organization," says Patricia Underwood, first vice president for the American Nurses Association. "They have a voice in the way patient care is delivered."
At Avera McKennan Hospital and University Health Center in Sioux Falls, S.D., "nurses are represented on over 90% of the hospital committees, so they have a broad voice in anything that affects clinical practice," says Carla Borchardt, Avera McKennan's director of professional practice. To earn the magnet designation, hospitals must first meet 95 standards that address the role nurses play in decisionmaking, Borchardt says.
In South Dakota, 72% of nurse employers report a nursing shortage, forcing some hospitals to limit admissions, close beds, curtail services or transport patients to other states, according to information from Colleagues in Caring, a public-private partnership working to fill the state's nursing pool.
Avera McKennan is waiting for its system board to approve nurse recruitment and retention initiatives that will cost the system about $2.2 million per year, according to officials. Those initiatives include pay and benefit increases, financial help to nurses continuing their education, and efforts to ensure nursing professors spend time with students in actual hospital units.
An education problem
In South Dakota and elsewhere in the country, educating nurses-and enough of them-is becoming more and more of a problem. From 1998 to 1999, the number of students enrolling in entry-level nursing baccalaureate programs dropped 4.6%, the seventh decline in as many years, according to the American Federation of Teachers' research. Graduation rates are no less problematic-the number of students graduating from nursing schools last year dropped nearly 7% nationwide, with the North Atlantic and Midwestern states hit hardest.
Like other providers facing a shortage of nurses, Geisinger Health System in Pennsylvania is trying to fill classroom desks itself. Forty-one students are enrolled in an associate degree program Geisinger is offering in conjunction with Pennsylvania State University. Under its program, Geisinger loans nurses money for their two-and-a-half year education in exchange for a four-year service commitment after graduation.
In areas that have most acutely felt the staffing crunch, officials recognize a need to support nursing education through dialogue among all those who contribute to it.
"Partnerships between education, government and the healthcare industry are essential, which is what we're learning in Colorado," says Patricia Uris of the Colorado Board of Nursing. "The collaboration will help resolve some of these problems."
To foster such collaboration, HealthOne Alliance has united hospital executives, nurse administrators, industry regulators and healthcare educators to create a center of nursing excellence. HealthOne will use initial funds of $250,000 to set up an office for the alliance to coordinate lobbying efforts and manage the distribution of nursing resources in Colorado.
Avera McKennan and other systems are engaged in similar efforts to foster symbiotic relationships between healthcare providers, nursing schools and government agencies. But until nurses' working conditions improve, according to industry sources, it may be difficult to attract more people to a profession often viewed as grueling work for little pay.
According to a recent online survey conducted by the ANA, 88% of nurses report that health and safety concerns influence their decision to leave the profession.
"We have to dramatically change the work environment such that (nursing) work is rewarding," says Exempla's Selberg. Hospital executives, he says, must ask themselves, "Do our systems support clinical staff? Is there a positive relationship between nurses and the medical staff?"
The ANA believes political action and public relations campaigns are essential but not if they can't promote nursing as a safe and professionally satisfying endeavor.
"If you don't have an environment that supports safe, quality practice-both for patients and nurses-then the nurses are not going to stay," says the ANA's Underwood. "They're going to turn around and leave, and that's not cost-effective for the hospital."
Further complicating the difficulty of keeping nurses on board is a rapidly aging nursing population. Today the average age of registered nurses is 45.2 years, compared with 36.3 years in 1980, according to the American Federation of Teachers.
As older nurses retire, they leave a vacuum in both hospitals and the schools that provide them with nurses. "Even if we get nurses into the profession, we won't have the experienced nurses to help them manage these intense, hectic environments," Underwood says.
As hospitals try everything to attract nurses-from eye-popping sign-on bonuses to money-draining temporary staffers-legislators are also weighing in.
Earlier this month Reps. Fortney "Pete" Stark (D-Calif.) and Steven LaTourette (R-Ohio) introduced the Safe Nursing and Patient Care Act of 2001, which is designed to keep nurses in their jobs by strictly limiting unpopular mandatory overtime practices. In May, the House and Senate introduced still-pending bills to spend $116 million over three years on nurse scholarship and recruitment programs.
Last month, Sen. William Frist (R-Tenn.) urged lawmakers to consolidate and pass two bills that would expand nursing programs and provide incentives for young people to join the profession. Meanwhile, nursing officials at the state level continue lobbying their local governments to enact similar legislation.
"The shortage is real and getting worse," says Kathy Apple, executive director of the National Council of State Boards of Nursing in Chicago.