Local news that is seen all over: The nursing gap | delmarvanow.com | The Daily Times

Delaware is facing a serious nursing shortage that could compromise hospital care for a growing number of sicker, older patients.

The U.S. Health Resources and Services Administration estimates that the state will be facing a shortage of more than 3,000 nurses by 2010 unless significant changes are made. The situation hasn't yet led to inadequate patient care here, as it has in other states, hospitals say. But nurses remain concerned that patient care will be compromised if changes don't occur.

Every Delaware hospital has unfilled positions for registered nurses. Nanticoke Memorial in Seaford has the highest vacancy rate, at 13 percent. That's followed by Beebe Medical Center in Lewes with 5 percent.
These vacant positions are typically filled by traveling nurses, who crisscross the state to fill gaps at short-staffed hospitals. They typically work at one hospital for three months before moving on to another.

Several studies have documented the dangers of inadequate nursing staffs, the most prominent being a 2003 report by the Institute of Medicine, which found that nurses in poor working conditions were contributing significantly to medical errors, including preventable deaths. Poor working conditions are defined by high patient-to-nurse ratios, mandatory overtime and fatigue on long shifts.

"Our state has been very lucky," said Penny Seiple, president of the Delaware Nurses Association. "Right now, we're doing better than a lot of other states. But unless we do things to make our environment better, it's going to be difficult to keep up with the need."

As the average age of patients has risen, so has the workload for nurses, said Loretta Ostroski, a registered nurse who helps manage Beebe's emergency department.

"With people living longer, you have higher volumes," she said. "Now there's a variety of medications for each disease process and we have to stay on top of the changes. We don't have much downtime."

One big issue is the increasing number of medications many older people are taking.

"When we're assessing and triaging patients, it's a lot easier to do that with someone who is taking two medications than someone who has 30 medications. It gets tricky when you're looking at what they're taking and what the doctor wants to give them," said Lindsay Decktor, an emergency room nurse at Beebe, which is treating a growing number of retirees.

Not only are individual patients taking more medications; the number of medications available to treat patients continues has grown significantly as well.

"You used to have 10 different meds you gave throughout the day," Seiple said. "Now you have (hundreds of) medications and you have to know how every one works and you need to know what the side effects are."

For hospitals to be accredited, the federal Joint Commission requires that they adequately manage patient flow and have safe staffing levels. The commission has found that reduced nursing staffs were a factor in almost one-fourth of the medical errors that resulted in deaths or serious injuries in hospitals.

But no national law exists that details what a proper patient-to-nurse ratio should be.

U.S. Rep. Janice Schakowsky, D-Ill., has sponsored a bill that would set registered nurse-to-patient staffing ratio requirements in hospitals, but the bill has not progressed.

The American Nurses Association says mandated ratios won't solve the problem. If a patient is significantly ill, for instance, a nurse may need more help than the ratio requires. But hospitals may not bolster their staffs because they would need to meet only the law's minimum requirements, said Cheryl Peterson, a senior policy analyst for the national nursing lobbying group.

"If you articulate what the ratio is in legislation, then that's all they'll do," she said. "That ratio may not be sufficient and may not meet the needs of the patients."

A study in the Health Affairs medical journal found that 6,700 patient deaths and 4 million days of hospital care could be avoided each year in the U.S. by hiring more registered nurses. The study also found that increasing nursing staffs actually would save hospitals money because they would paying less in the way of settlements for malpractice lawsuits.

While nurses work in outpatient institutions, doctor's offices, nursing homes, private homes, day treatment centers, government agencies, schools and retirement communities, the demands on them generally are greatest in hospitals.

When too few are on a hospital floor, crucial tasks such as evaluating a patient's medications and preventing bedsores might not be performed. Sometimes, nursing duties fall on workers who are less skilled, said Peterson of the American Nurses Association.

Nursing student Brie Crabill has seen the stress on registered nurses during her clinicals, the hands-on portion of the nursing program where students are exposed to various health care environments and types of patients.
"Nurses now are frazzled, they're caring for six to eight patients and that doesn't sound like a lot, but these are six to eight patients who are on 10 to 15 medications each," she said. "You're constantly giving meds, constantly checking to see if patients aren't having adverse reactions and it gets hard."

The median age of a Delaware nurse is 44, according to the Delaware Health Care Commission's most recent report. The U.S. Bureau of Labor Statistics reports that the nursing profession is aging and retiring at twice the rate of most occupations.

But merely filling in retirements with new nurses isn't the solution, said Esler, the interim vice president of patient care services at Beebe.
"Nursing isn't something you can do with excellence just stepping out of the gate," she said. "It takes years to really be an excellent nurse. The concern is whether there is going to be enough nurses and whether those nurses are going to have the skill set and experience."

Some hospitals also are taking steps to address the shortage. Hospitals with nursing schools, like Beebe, are looking to expand. Most also offer sign-on bonuses. Some have gotten more creative, starting online auctions where nurses can bid on extra shifts and offering 9 a.m.-to-2 p.m shifts for nurses who are mothers so they can work while their kids are in school.

Bayhealth offers a six-month orientation program for new nurses, and four years ago launched an initiative to recruit enough nurses to address its expected turnover of about 10 percent. The health system recruits from almost 30 college and university nursing programs, up from seven nursing programs five years ago.

"A couple things are going to happen when you make the hiring of nurses a priority," said Marianne Foard, a registered nurse and manager of professional recruitment and retention at Bayhealth. "You will have improved patient outcomes and you will have a nursing work force that is satisfied. Nurses stay in the profession for two reasons: They have job satisfaction and they are engaged in their practice."