Is there a nurse in the house?

Terrorism adds to difficulty in recruiting enough nurses to overcome shortfall and meet new mandates

Nurse Sharon Bateson: “They’ve taken away all our responsibilities except for what the law requires.”

Nurse Sharon Bateson: “They’ve taken away all our responsibilities except for what the law requires.”

Emergency workers are this country’s newest heroes. Law enforcement officers, firefighters, paramedics, doctors and nurses—the front-line troops during tragedies, either natural or man-made—care for people at their worst and most needy. They are among society’s most emotionally demanding jobs.

But in the wake of September 11, such roles are some of the most widely respected. Now, instead of admiring pop stars and pro athletes, people are seeing the dedication and courage of rescue workers in New York City and Washington, D.C., in a new light, and transferring that appreciation to people working in their own communities in similar capacities.

And people seem to want to be these heroes. Agencies and colleges are fielding inquiries in record numbers about the requirements for becoming firefighters, paramedics and police officers, or even enlisting in the military and reserve units.

But this trend isn’t carrying over to the nursing profession, even though nurses generally are positioned on the front lines of treatment and rescue, and despite the fact that California is trying to overcome a shortage of nurses.

“I tend to think when you look at the images on TV, it’s the paramedics, the firefighters you see. There were so many fatalities, you didn’t have the influx into the emergency rooms,” said Liz Jacobs, spokeswoman for the California Nurses Association. “There isn’t the public recognition of nurses as heroes.”

Instead, the terrorist attacks and the spate of anthrax-laden letters may threaten an already dwindling supply of nurses, says Jacobs, describing an informal survey of emergency-room preparedness that reveals staff members aren’t being trained to address and treat the new threats of bioterrorism.

“In California, a bad flu season or an earthquake is much more certain than a terrorist attack. Emergency rooms are already maxed out,” she said. “Now, people go to the E.R. with fears of anthrax exposure and it’s the E.R. nurses who will console them and treat them.”

It’s a critical time for the nursing profession. CNA and hospitals alike are awaiting direction from the state Department of Health Services on the implementation of Assembly Bill 394, which will mandate statewide nurse-to-patient ratios beginning January 1. The ratio mandates are expected at any time.

Opponents of the new requirement ask where the nurses are going to come from. Should the legislation be implemented in January 2002, they say many hospitals would fail to meet compliance and could be shut down.

“Given the shortage of RNs, we asked (Department of Health Services) to be mindful it’ll be difficult to increase the pool of RNs,” said Cinde Breedlove, spokeswoman for Kaiser Permanente.

While CNA and the hospital industry have conducted research and developed their own set of numbers, AB 394 directs the DHS to mandate appropriate nurse-patient ratios. In the two years since the bill was passed, the DHS still struggles to define those numbers.

“There’s no scientific evidence anywhere that says any ratio anywhere gives better outcomes for the patient,” said Jan Emerson, vice president of external affairs for the California Healthcare Association, an organization that represents hospitals statewide. “There isn’t anything to say ‘a-ha, this is what we can hang our hats on.’ ”

While raising health concerns for would-be nurses and not increasing demand, the events since September 11 have helped the situation in some ways. Governor Gray Davis signed a bill on October 8 to address the shortage by providing $5 million to support nurse training.

It provides $1 million in grants through community colleges to develop a specialty nurse training program. Health-care industry partners must match, either in funds, mentors or training, and show a shortage of trained nurses in one area: emergency room, intensive care, neonatal, obstetrics, pediatrics or operating room.

The other $4 million is targeted to boost nursing enrollment at community colleges which, according to the bill’s sponsor, don’t always have space for every interested student.

“The aging of the (nursing workforce) exacerbates the shortage and underscores the need for increased education and training for new nurses,” Assemblywoman Hannah-Beth Jackson, (D-Santa Barbara) said in a written statement. “This bill will help to address California’s nursing shortage by providing training for thousands of those who wish to become nurses.”

Los Rios Community College District, which offers nursing programs on two of its four campuses, says it’s been discussing ways with the hospital association to graduate more qualified nurses.

“Nursing is a high-cost program. And accreditation requires very low instructor-student ratios,” says Susie Williams, director of communications. “That funding could help us increase staff and increase facilities, particularly the clinical labs.”

But, with a few million dollars to spread across 71 community college districts, Williams says the funding could be a mere band-aid for a hemorrhaging system. The bill’s language is rather vague as to what the money means for actual enrollment, she says, but it’s better than nothing: “Clearly anything that helps colleges to graduate more qualified nurses is beneficial.”

Nursing isn’t the only profession to see a shortage in the labor pool. California’s population growth is somewhat responsible for other deficits, including a widely publicized teacher shortage. An estimated 350,000 more teachers are needed in the next five to seven years, according to state Department of Education information.

Yet the nursing shortage is being exacerbated by the changing dynamics of the job itself. The number of registered nurses increased 5.4 percent from 1996 to 2000. But the percentage of nurses who work in acute care settings, like hospitals, is down to 59 percent, according to a February 2001 survey of the Bureau of Health Professions.

In short, nurses are dropping to part-time status, retiring early, choosing to work in public and community health settings, health departments and with home health agencies, rather than acute care settings like hospitals.

“Our contention is there isn’t a nursing shortage. There are many nurses leaving the field because of the working conditions,” said Jacobs. “A 1997 Bureau of Registered Nursing found 17 percent of nurses are not working. A report by the California Workforce Initiative shows a significant number of nurses would return and boost the workforce an estimated 4 percent.”

When nurses complain about their workload and stressful working conditions, it’s not the job responsibility they’re complaining about, it’s the number of patients for which they have to care on an hourly basis, says Sharon Bateson, a nurse with Sutter Roseville.

In short, it’s the aspects of care nurses no longer have time to do that make the profession a satisfying one.

“They’ve taken away all our responsibilities except for what the law requires. A wound care team changes the dressing, for example,” Bateson said. “But it’s like they’ve taken a piece of that patient away if I don’t see the wound and how it’s healing and whether there are signs of infection. They’ve taken away pieces of care so that I spend less time in the room.”

Not only are nurses charged with more patients than they say they can effectively cover, they also say patients are sicker.

“In some of the areas where I work, patients in the Medical-Surgical Unit are as sick as those who used to be in ICU,” says Wendy Wilson, a nurse with Kaiser Permanente. “With the acuity of the patient so much higher and hospital stays shorter, there are more multi-faceted tasks nurses have—giving information to the doctor, the physical therapist, ordering lab work, and working with the discharge planner and the family about patient education.

“Sometimes I have to say that people fall through the cracks. People aren’t ready to go.”

Belinda Morieson, head of a union called the Australian Nursing Federation, recently visited California to tell of that country’s experience implementing nurse-patient ratios. She claims an absolute turnaround from three years ago, when the country faced a nursing shortage crisis. Like California, nurses were “voting with their feet and leaving.”

Since the ratios were implemented in August 2000, the supply of nurses has jumped 13 percent, Morieson says, pointing out that the staffing levels are similar to what the CNA is seeking.

“To get your job satisfaction, you don’t get it from leading a glamorous life—you get it from looking after patients properly,” she said.

And the ratios offer cost savings for hospitals, she says, ticking off reduced sick leave; reduced staff turnover; and reduced reliance on contract nurses, whose daily wage averages about 20 percent more than a salaried nurse.

While the CNA takes issue with Kaiser for requesting a five-year delay in implementing AB 394, Kaiser has endorsed a staffing standard that two unions submitted to DHS: the United Nurses Associations of California and the Service Employees International Union Nurse Alliance.

While the staffing proposals don’t drastically differ in numbers, Kaiser is asking for a transition period “to build the pool of available nurses, and for some allowance for workforce planning needs once the new standards are in effect,” according to a letter from Kaiser management.

For now, hospitals are preparing for the ratio legislation to take effect, says California Healthcare Association’s Emerson.

“It’s possible there will be a phase-in period, maybe over six months, perhaps for different units. It will be in effect January 1, but how DHS chooses to implement it is unknown,” she said. “Our proposal is 1-10, but we hope to use the number as a base to adjust staffing upwards, according to patient needs. To just put in a number, a rigid number, we don’t believe is in the best interest of the patient.”