To gain some perspective on the scope of the nursing crisis facing Los Angeles, the Business Journal assembled a group of seasoned professionals to air their views on the problems and possible solutions. Participating in the roundtable discussion were: Linda Burnes Bolton, chief nursing officer at Cedars-Sinai Medical Center; David M. Johnson, assistant director of the collective bargaining division of the California Nurses Association; Gloria Gilbert Mayer, president of the Institute for Healthcare Advancement; Barbara Kaye Patton, health care consultant with The Camden Group; Stephanie Rhu, vice president of patient care services at San Pedro Peninsula Hospital; and Lynne A. Whaley, senior vice president of patient care services at Long Beach Memorial Medical Center and immediate past president of the American Conference of Nursing Leaders.
Question: Is there really a nursing crisis in Los Angeles?
Bolton: There is definitely a crisis in nursing. And the No. 1 crisis is the shrinking workforce. The crisis facing Los Angeles, as the California Nurse Strategic Plan has clearly illustrated, is that we have fewer individuals coming into the profession significantly less. And we have more individuals retiring out of the profession, so that in the next 10 years a mere 10 years we will be in an era where we have a public health crisis.
By public health crisis, I mean that no matter what the geographical setting a clinic, acute care institution, a community setting the numbers are just not there, because the demand has gone up significantly.
Mayer: Nursing is not one profession, nursing is many professions under the name of nursing. But what we're talking about is the staff nurse at the bedside, not the nursing administrator. The crisis the consumer sees is, "I'm sick, I have a mother who's sick, I'm in a hospital" and nurses aren't there. That crisis is real.
Q: But aren't there actually more nurses working today than in years past?
Whaley: The number of nurses working has increased, but the percent of time they work has decreased. So if you do the economic analysis, you find that overall the number of full-time equivalent individuals working is less. Why? Because we have a booming economy, and in a booming economy, particularly in a two-income family, you don't necessarily need both spouses to get benefits.
Q: So what are all these part-time nurses doing with the rest of their time?
Rhu: I'd be willing to bet that, in my particular institution, 70 percent of the nurses work a second full-time job, and that makes them less available to me. But they're also looking to do other things (besides work). They're aging the average age for a staff nurse in the United States is 44; in California it's 46. People are looking to retire. They don't want to bounce around (from job to job). They aren't mobile anymore.
Q: So that steadily aging population of nurses seems to suggest that nursing school enrollment has been falling. Is that true?
Whaley: Yes. It started during the '90s, when managed care came in and the schools of nursing said, "Maybe that's not where we want to put our money in the universities and local colleges." Actually, some schools of nursing closed. Short term, the number of slots dwindled and you had students waiting five years to get an associate's degree. Rather than face that, people have gone into other professions. The number of students that we produce every year has decreased.
Johnson: Even many of those who do graduate don't stay long. I hear all the time from new grads who come into hospitals and leave. They leave for a variety of reasons, but principal among them is what they're required to do on a daily basis. The kind of care that they're required to provide, with the kind of resources that they have, in the time that they have to do it, is just untenable and they can't take it. That's one of the issues that needs to be addressed in the industry. You can't be driving out the new grads coming in, or the nursing shortage just gets worse.
Q: Why should anyone undertake the rigors of being a nurse when they could make a lot more money at a dot-com?
Mayer: Maybe so, but managed care has opened up incredible opportunities for nurses. Even dot-coms the ones that are health care-oriented use nurses. There's so many opportunities for everybody out there. Even nurses who go into the hospitals and get the training for three to five years they can then go on to an HMO, or one of these telephone-advice systems. It's good for the profession to say you're not locked into one thing. I can tell my daughter, I can tell everyone, "Go into nursing."
Johnson: Pay is an issue, given that there are a lot of other opportunities for people coming out of college. But the biggest complaint that we hear from our members is not about pay; it's about the quality of care that nurses are able to provide in a healthy environment and the frustrations that nurses have with working short-staffed, with not being given the adequate resources, providing the quality of patient care that they want to provide.
Q: So emotional satisfaction remains the main enticement?
Johnson: A lot of our members go into nursing not for financial reasons they're attracted to it because of the nature of the work. So when they feel that decisions are made that are based more on increasing the bottom line as opposed to improving the quality of the patient's care, a lot of our members feel increasingly that their work is not really valued. And in some cases, they feel like they're putting their patients in jeopardy.
Q: It sounds like the same type of complaints that patient advocates have been lodging against HMOs. Are we seeing improvements on the quality-of-care front?
Bolton: It depends on who you talk to. I think there is a commitment from all health care institutions to provide the best quality care, and they do that by looking at factors within their organization, labor being one part of that. It's certainly a crucial part, but it's not the only part. There's also the design of the health care system itself, which can contribute to medical errors.
Q: But even if you were to improve the care-delivery system, wouldn't we still be faced with a severe shortage of nurses?
Mayer: Sure, but every single decade there's been a severe shortage. This is not a new problem. It goes up and down, up and down. There's a shortage and then it becomes an overage. Plus, unemployment is the lowest it's ever been right now, so there's a shortage of a lot of people in a lot of professions.
Q: So with nurses already complaining about being overworked and not having enough time to personally connect with patients, and that situation expected to worsen, what can be done?
Bolton: We came up with a project called "therapeutic time," which says that, no matter what you're doing, there's a time during the course of your shift that you go and you're present with the patient. You sit there and you dialogue with the patient. Well, that has had a phenomenal effect on the nurses because they can walk out at the end of the day and know that they connected. Yes, they did all the IVs and they did all the this-and-that. But they connected.
Johnson: While I think the idea of nurses getting "therapeutic time" with their patients is laudable, the reality that our members are pointing out every day is that they have no time even to provide the bare minimum, much less spend additional time. I would disagree that things are getting better. It's our distinct impression that things are actually getting worse, in terms of conditions for registered nurses.
Q: Can technology play any role in freeing-up nurses to spend more time with patients?
Mayer: Health care has been very behind in technology, but technology has helped, with such practical aids as blood-pressure cuffs, IV bottles I think we have to look at technology for the next big help.
Q: So should people with different skill sets, those with more of a tech background, be recruited into nursing? And should recruitment efforts be directed at a younger audience?
Rhu: The Coalition for Nursing is looking at how we portray the image of nursing, doing public service announcements and putting together a formalized program to inform children in grade school about careers in nursing, and the wide variety of options. So there is some work being done in that regard.
Q: But who pays for that? Health care costs are already going up again, despite cost savings from the shift to managed care.
Mayer: Obviously, it has to be employers that foot the bill, because that's who pays for health care in the U.S. with the government being the largest employer. People bash managed care, but it's really not managed care, it's really economics. There was one point where health care costs were going up 12, 15 percent a year, and businesses couldn't handle it.
Q: Are the unions acknowledging that ultimately hospitals and HMOs are not to blame for the problems plaguing health care, but that the ultimate culprits are employers who are unwilling to ante up?
Johnson: We would disagree with the idea that the problem is adding significantly more money. One of our fundamental concerns is the way the current money in the health care industry is being utilized. There are a lot of private corporations making a whole lot of money off of health care and that's currently going into investors' pockets. Part of what needs to happen is a shift in resources and a shift in money away from private investors' stock returns and into actual health care.
Q: Obviously, the nursing crisis is a national problem. Is there anything about the situation in Los Angeles that makes it unique?
Mayer: The large number of Spanish-speaking patients is a concern, having enough dual-language nurses. I know the second-greatest foreign language in L.A. is Armenian, in Orange County it's Vietnamese. I think that makes it more complex because having a nurse or other health care professionals who speak that language makes a big difference.
Patton: There's Armenian, there's Chinese, Cambodian the melting pot of L.A. is truly difficult at a care level when you have languages and cultural differences, not only among the staff and the physicians and patients, but patient to patient. It can be very, very complex. And they don't necessarily come to the United States to work in a hospital. We don't have a large base of Armenian, Chinese nurses. The women in those cultures aren't flocking into nursing.
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