CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
A STUDY OF THE NURSING SHORTAGE PROBLEM
IN THE HOSPITAL
A graduate project submitted in partial satisfaction of the
requirements for the degree of Master of Science in
Health Science/Health Administration
by
Ronald Kupferstein and Nancy Yudin
August, 1981
The Project of Ron Kupferstein and Nancy Yudin
is approved:
A~ G.
Herkimer, M.B.A~
Ruth'K. Nagel, M.S.
Q
California State University, Northridge
ii
TABLE OF CONTENTS
Page
v
LIST OF TABLES
vi
LIST OF FIGURES
ABSTRACT . .
vii
. .
Chapter
1.
INTRODUCTION .
1
Introduction
1
Statement of Problem
2
Statement of Problem
2
Significance of Problem
2
Description of Study Type
4
Organization of Paper
2.
BACKGROUND . .
7
8
Review of Literature
Government Funding for Nursing
Education
8
8
Voluntary Effort
11
Causes of Nursing Shortage
14
Registries . . .
26
Setting of Project
36
iii
Chapter
3.
Page
METHODOLOGY
37
Statement of Problem
4.
5.
37
Objectives
37
Definition
37
Sources of Data and Their Measurement
38
Analysis
39
RESULTS
41
Findings
41
Limitations
52
CONCLUSIONS, RECOMMENDATIONS, AND
SUMMARY
54
Conclusions
59
Recommendations
60
Summaryf
62
REFERENCES
64
APPENDIX .
72
iv
LIST OF TABLES
Table
Page
1.
Demographic Profile of Today's Nurse . .
2.
Story in Statistics:
3.
Registry Rates
44
4.
Hospital Nurse Salaries
45
5.
Variable Staffing for Hospital Nursing
Stations . . . . . . . . . . . . . .
46
6.
Daily Requirements--Total Nursing Hours
47
7.
Daily Requirements--Nursing Hours by Shift
and Nursing Level
48
8.
Registry Utilization
49
9.
Calculations for Cost per Day for
Supplemental Nurses . . . . . .
50
Demand and Supply
v
5
16
LIST OF FIGURES
Page
Figure
1.
How Well Does Your Present Job Meet
Your Needs?
. . .
22
2.
ANA Sets Guidelines for Agency Use
28
3.
Gourmet Menu for Retention
56
vi
ABSTRACT
A STUDY OF THE NURSING SHORTAGE PROBLEM
IN THE HOSPITAL
by
Ron Kupferstein and Nancy Yudin
Master of Science in Health Administration
An acute nursing shortage has created problems for
the hospital industry with respect to quality of care and
cost of delivering that care.
This project sought to (1)
provide an overview of nursing, (2) identify causes of the
nursing sportage, (3) quantify the costs associated with
this shortage, and (4) offer recommendations toward a
solution to this problem.
Chapters 1 and 2 provide information on nursing
history, nursing shortage, and nurse registries.
Chapter 3
quantifies, by case example, the cost of not having a
permanent nursing staff in a hospital.
findings of the project.
Chapter 4 presents
Chapter 5 discusses solutions
currently in use and additional recommendations.
vii
Many factors contribute to the nursing shortage,
(,
including, but not limited to, (1) unmet job expectations
by the nurse,
nurse,
(2) conflicts between the doctor and the
(3) poor hospital working conditions, (4)
unsatisfactory relationships between the nurse and the
administrative staff, and (5) limited opportunity for
career advancement.
The emergence of registries--supplemental staff
agencies--seems to be part of the problem as well as a
solution.
This project demonstrated that reliance upon
registries to fill voids in permanent nursing staff is
costly and reduces quality of care.
Approaches by hospital administrators to solve the
shortage problem include hiring of nurse recruiters to
flexible time schedules.
Some hospitals have learned to
cope with the problems of shortage; others are overwhelmed.
Hospital management must give attention to and deal with
the causes of the problem.
The philosophy of managing
the nursing shortage must shift from curative care to
preventive care.
viii
Chapter 1
INTRODUCTION
The following chapter presents the introduction to
the project, the statement of the problem, and the
organization of the project.
Introduction
Since the Nixon Administration lifted wage and
price controls, there has been an alarming rise in the rate
of inflation in the hospital industry.
In an attempt to
provide a solution to this major problem, the hospital
industry and its affiliates have attempted to reduce this
rate of inflation by establishing a "voluntary effort" cost
consciousness plan.
The aim of this plan is to reduce the
rate of inflation in the hospital industry by 2 percent per
year over the next three years (72).
A major factor
contributing to this inflationary rate has been the
shortage of permanent nursing staffs in hospitals.
As a
result, hospitals have been forced to turn to alternative
methods of staffing which have not been cost effective and,
in fact, have tremendously added to the problem of
inflationary hospital care costs.
1
2
Statement of Problem
The following section details the statement of the
problem, the significance of the problem, and the
description of the study type.
Statement of Problem
A definite nursing shortage in the hospital has
developed and has become evident as the decade of the 1980s
is entered.
This nursing shortage is defined as the
inadequate supply of registered nurses available and
willing to accept employment in institutional settings
under prevailing conditions in the area (70).
The problem
of this project, through the review of literature and a
case study, was to:
1.
Provide an overview of nursing,
2.
Identify the causes of the nursing shortage,
3.
Quantify the costs associated with this
shortage, and
4.
Offer possible recommendations to this problem.
Significance of Problem
As this nursing shortage problem becomes more
acute, it is affecting the quality of nursing care and
continually contributing to skyrocketing costs.
According
to a Minnesota study, nursing staff turnover is an
important factor in
3
. (1) financial costs to the hospital of
recruitment selection, repeated training and increased need for supervision, (2) emotional cost
to the staff from poorly integrated, low-performing
and constantly changing personnel, and (3) quality
costs to patients from uneven standards of care and
repeated breaking of staff-patient relationship.
(59:17)
The National Commission on Nursing reported that
88 percent of United States hospitals are unable to fill
full-time nursing positions.
The national turnover rate
of registered nurses is 30 to 40 percent (21).
The problem
in California closely parallels that of the United States.
A 1979 study by Los Angeles-based J. D. Powers and
Associates noted that,
. in the midst of the largest supply of
registered nurses in the State of California, we
are faced with the most serious shortage of registered nurses ever.
The crucial shortage provides
higher operating costs, limited revenue, and
deteriorating images of health-care facilities.
(66:20)
Further, a California Hospital Association study found that
20 percent of budgeted nursing positions in hospitals were
unfilled in 1979 as compared with 17 percent in 1978 and
14 percent in 1977 (45).
Of the over 180,000 registered
nurses currently licensed in California, one half are
employed and 50,000 of these nurses are employed in
hospitals (47).
4
Description of Study Type
This project was a descriptive study to determine
the costs of not having a permanent nursing staff in the
hospital.
The model hospital was a non-identified southern
California full-service, 160-bed, general acute hospital.
A comprehensive cost analysis was conducted, indicating the
costs associated with this typical hospital which utilizes
registries and nonpermanent staff as compared with the
costs of a totally permanent staff.
In order to accurately assess the problem of the
nursing shortage, today's nursing professional must be
analyzed.
Fifty-seven percent of today's nurses are
between 25 and 44 years of age, 68 percent are married, and
61 percent have children.
Only 33 percent of the nurses
are the sole income earner of the household.
have practiced
n~rsing
Forty percent
for three to ten years, while 43
percent have practiced nursing for ten years or more
(46:2-3).
Table 1 provides a demographic profile of
today's nurse.
Nursing continues to be a predominantly female
profession.
The 1977 National Sample Survey conducted by
the American Nurses Association indicated that there was
only a slight increase in the number of males licensed as
nurses, from 1.3 percent in 1972 to 1.9 percent in 1977.
Males comprise 4.7 percent of registered nursing programs.
5
Table 1
Demographic Profile of Today's Nurse
57% . . . . . . . . . . . . . . . . . . . . . . 25 to 44 years
Years in Practice
40%
43%
3 to 10 years
10 years or more
Marital Status
68%
30%
Married
Unmarried
Children
61% . . . . . . . . . . . . . . . . . . . . . . Have children
(average number of children is three)
Income Status
33%
62%
Sole income earner
Contributing to income
Level of Nursing Education
21%
53%
21%
3%
A.A.
Diploma
B.S.N.
M.S.N.
Ethnic Origin
86%
4%
7%
1%
White
Black
Oriental
Chicano
6
Table 1 (continued)
Work Role
Staff
Head nurse/supervisor
Education
Community health
Doctor's office
53%
16%
3%
4%
5%
Source:
(46:2-3)
According to Jo Perry, the coordinator for nursing
recruitment for the Regional Hospital Administration, it is
a common trend for women in most careers to drop out of the
working force.
Nursing is no exception.
Knopf
longitudinally studied 6,000 nursing graduates both one and
five years postgraduation.
The study revealed that "one
year postgraduation, almost all nurses were employed in
nursing and usually in full-time positions."
New nurses
are young and unmarried and there is a "universal
propensity" for the young to marry and have children.
Knopf's study reported that five years postgraduation,
7 out of 10 respondents were married and 75 percent of
these had children.
According to Knopf, a "financial
unnecessity is created when the spouse of a nurse is an
adequate income provider."
(7)
7
Organization of Paper
This project is organized in the following manner:
Chapter 1 has provided an introduction to the project, the
statement of the problem, and the organization of the
paper.
Chapter 2 reviews pertinent literature regarding
nursing history, nursing shortage, and nurse registries.
Chapter 3 quantifies, by case example, the cost of not
having a permanent nursing staff in a hospital.
presents the findings of the project.
Chapter 4
Chapter 5 discusses
possible solutions currently in use as well as offering
additional recommendations.
Finally, a bibliography and
appendices provide appropriate reference to the text of the
project.
Chapter 2
BACKGROUND
This chapter presents a review of literature and
the setting in which the study was conducted.
Review of Literature
The review of literature is presented in four basic
areas:
(1) government funding for nursing education, (2)
voluntary effort, (3) causes of the nursing shortage, and
(4) nursing registries.
Government Funding for
Nursing Education
Since the enactment of the Social Security Act of
1935 which provided grants for nursing education, the
United States government has shown its concern for nurse
manpower education.
The United States Cadet Nurse Corps,
created by the Bolton Act (1943), provided federal
assistance for nursing education.
The Health Amendments
Act (1956) authorized a traineeship program for the
education of nurses for positions in teaching,
administration, and supervision as well as traineeship
programs for public health staff positions.
8
9
The Nurse Training Act of 1964 established
assistance for a five-year program which would lead to an
increase of 75 percent in the annual number of nursing
school graduates by 1975.
This act had two goals:
(1) to
improve the quality of the existing and future supply of
nurses and (2) to bring about a substantial increase in the
quantity of professional nurses by 1975.
The Health Manpower Act of 1968 expanded and
extended the areas of assistance covered by the 1964 Nurse
Training Act.
The Health Manpower Act expired on July 1,
1970; however, Public Law 92-52 extended student loan and
scholarship provisions for one year.
The Nurse Training
Act of 1971 expanded and continued the nurse training
action of the Health Manpower Act.
The Nurse Training Act
was the largest authorization for nursing and included a
program of capitalization grants.
In 1978, President Carter vetoed the Nurse Training
Act.
The Congressional Budget Office, in a report to a
Senate budget committee entitled Nursing Education and
Training:
Alternative Federal Approaches, advised that
the
. . . supply of registered nurses through 1990
is likely to be sufficient to meet the combined
demands of National Health Insurance, growth of
Health Maintenance Organizations and expansion of
nursing roles.
( 77:55)
On October 11, 1979, however, after passage by the House of
10
Representatives and Senate, President Carter signed a
Health Planning Bill which funded nurse training programs.
The passage of Proposition 13 in California has
restricted increased educational funding by local sources.
This affects community college-based programs which are the
most expensive programs in the community college system.
Legislation was introduced into the Ninety-seventh Congress
by HB 2004, sponsored by Waxman (shortened title is Health
Professionals Education Assistance and Nurse Training
Amendments of 1981).
This bill reauthorizing federal
health professions and nurse training programs for the
fiscal year 1982-83 was passed.
A leaner version of
HB 2004, S.799 sponsored by Hutch, has also been introduced
(23).
Since World War II, America has been expanding its
health care systems.
The Hill-Burton program was passed by
Congress to build facilities to treat the ill.
Medicare
and Medi-Cal were passed to provide medical care to those
who lacked the resources to receive appropriate care.
1960s was the decade of access to medical care.
The
Medical
technology lengthened the average lifespan and attributed
to a higher quality of life.
Health personnel and medical
and nursing school enrollments increased.
In the 1970s, quality of care was emphasized.
Quality assurance programs were developed.
Patient days
11
increased along with number of employees per bed, number of
nursing hours per bed, number of doctors and nurses per
patients, and number of employees per capita.
Along with
these increases came the inevitable increase in costs.
Voluntary Effort
In 1972, the Nixon Administration lifted the final
phase of the wage and price controls.
The healthy industry
was unprepared when President Nixon first instituted the
"freeze."
As a result, in 1972, the health industry vowed
never to be unprepared again.
Almost immediately, prices
rose and health industry employees received higher wages.
There was a dramatic increase in the cost of health care-approximately 11.6 percent in 1972 (62:56).
was a similar increase.
In 1973, there
Controls were no longer in force
and there was a tremendous boom in the industry:
new
hospitals were built, old hospitals were refurbished, new
technology was being used, and an increasing demand for
health services was felt.
The inflation rate of health
care rose·steadily to 17.8 percent in 1974, 17.5 percent in
1975, 19.6 percent in 1976, and dipped in 1977 to 15.6
percent (62.58).
These rates of inflation were
consistently higher than the general rate of inflation in
the United States.
12
Many factors have contributed to the rising cost of
health care.
Possibly this may be attributed to the fact
that health care is virtually a noncompetitive industry.
The patient/consumer is likely to select the family
physician but not the specialist (he/she is referred by the
family physician), nor the hospital (a physician is the
only one who admits patients to a hospital), nor the
services which can only be prescribed by a physician.
Second, hospitals are reimbursed by third-party payors
(i.e., insurance companies) based on whatever price the
hospital states a service costs.
Third, from 1957 through
1977, salaries in the health industry increased 231
percent, whereas the national increase of wage earners was
only 143 percent over the same time period.
From 1973
through 1977, malpractice rates skyrocketed from $100
million to $1 billion.
Governmental regulations on the
industry have added over 20 percent to the "real" charges.
In 1965, the federal government enacted Titles XVIII and
XIX (Medicare and Medicaid) which added tremendously to the
load on the industry.
A major point in discussing the rising cost of
health care is fragmentation.
This is a result of
overlapping of services, maldistribution of services, and
overutilization of these services.
Finally, many in
today's society have indicated belief that the most
13
expensive is often the best form of treatment.
Due to this rising cost of health care, particularly
in hospitals, the Carter Administration, in the spring of
1977, announced the proposal of the Carter Hospital Cost
Containment Act.
This act proposed a limit on the amount
of reimbursible charges for the fiscal year 1978 to
9 percent above the average charge for fiscal year 1977.
The industry viewed this as not only a threat to its
economic independence but more of a threat to the level of
care that the United States had acquired and wanted to
build.
In November, 1977, voluntary cost containment
began with a challenge by United States Representative Dan
Rostenkowski, then Chairman of the Subcommittee on Health
of the House Ways and Means Committee.
His subcommittee
was unable to act on proposals to limit hospital revenues
and capital expenditures during that season of Congress.
The main proposal had been to put a 9 percent cap on
increases in hospital revenues and/or expenditures.
This
9 percent, according to the health care field, would have
compromised American standards of health care.
Hospitals were being given a grace period to try to
contain costs themselves.
The voluntary effort began
through the coordination by the American Hospital
Association, the American Medical Association, and the
14
Federation of American Hospitals of hospitals, doctors,
health equipment manufacturers, insurance carriers,
business, labor, consumers, and local government to band
together to contain increases in health care while
maintaining the high quality of American health care.
The
goal of the voluntary effort was to decrease the rate of
increase in community (nongovernment) hospital expenditures
by 2 percent per year during 1978 and 1979 so that the
difference between the rate of increase in the gross
national product (GNP) and hospital expenses were reduced.
Thus, hospitals could gradually slow their increasing costs
without necessarily impairing the quality and accessibility
of medical services.
In 1978, the first year of the
voluntary effort, the rate of expenditure increase was
12.8 percent, 2.8 percent less than the 1977 rate.
The
goal for 1979 was to further reduce expenditures to 11.6
percent (63).
Causes of Nursing
Shortage
There have been many changes in the scope of health
care services in the hospital which have increased the
complexity of the nurse's role.
The rise in the population
of the aged has increased the demand for specialized
nursing services in therapeutic and rehabilitative care.
The shortened hospital stay caused by increased technology
15
has required an increased number of nurses per patient.
The nurse is constantly required to attain enormous amounts
of new knowledge to keep pace with changing innovations in
technology and the emphasis on specialization in nursing
practices.
The nurse is influenced by complex ethical and
philosophical questions regarding health care delivery.
The need for manpower interdependence is seen in the "team
approach" to providing health care.
The trend toward
consumerism is creating a need for nurses to learn more
about patient education and alternative health care
services.
The hospital is facing an increased demand for
nurses in the face of a decreased supply (see Table 2).
The 1977 National Sample Survey conducted by the American
Nurses Association showed that 27 percent of those nurses
licensed to practice were not employed in nursing and were
not looking for nursing employment at the time of the
survey.
The survey also reported that 32 percent of the
70 percent of employed registered nurses were working
part time (45:2).
Nurses were switching from hospital
positions to nonhospital positions such as nursing homes,
extended care facilities, public health agencies, and
physician or dentist offices.
The Geographies Distribution
Study in 1975 indicated that the mean length of stay on a
job in nursing was about two years.
Recent studies show a
16
nurse turnover rate of 35 to 60 percent which puts a burden
on the hospital for constant orientation (45:3).
Table 2
Story in Statistics:
Demand and Supply
Demand
Estimated national shortage of
hospital nurses . . . . . . . . . . . . . . . . . . . 100,000
Nursing vacancies in nursing
homes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150, 000
Full-time RN positions open
per average U.S. hospital ......... 72
Hospitals unable to fill fulltime nursing positions ............ 88 percent
National turnover rate of RNs
30 to 40 percent
Projected number of full-time
equivalent (FTE) nurses
needed in 1982 . . . . . . . . . . . . . . . . . . . . 1,219,300
New nursing jobs by 1985 . . . . . . . . . . . . 240,000
Supply
RNs licensed to practice in
the U.S. . . . . . . . . . . . . . . . . . . . . . . . . . . 1, 400, 000
RNs employed in nursing ............. 980,000
Nursing school applications ......... 16 percent decline
(1977 to 1978)
Nursing school admissions ........... 2.9 percent decline
(1978 to 1979)
RN graduations . . . . . . . . . . . . . . . . . . . . . . 78,000 (1980) ~
Source:
(45:4)
17
The National League for Nursing counted 765 fewer
nursing graduates in 1979 than in 1978, the first drop in
over a decade.
According to one survey, there was a 16
percent decline in nursing school applications in 1977
to 1978 and a 2.9 percent decline in nursing school
admissions from 1978 to 1979.
The American Nurses Association estimated that
420,000 nurses are out of work.
More than 90 percent of
California hospitals are experiencing problems recruiting
registered nurses with the most serious problem occurring
in the southern part of the state and in large- and
medium-sized and rural hospitals (66).
The solution to the nursing shortage problem seems
to be in discovering why fewer persons are entering the
profession and why more persons are leaving the profession.
One cause of the nursing shortage appears to be the unmet
expectations of the nurse.
The nurse comes to the work
force with a more advanced academic background, an
increased knowledge of patient care, and a greater
professional commitment to advance in the nursing field.
Newly graduated nurses demand individual job freedom to
take on decision-making responsibilities and accountability
for their patients.
Brody contended that "drastically different
educational and occupational conditions are a major
18
contributor to the shortage."
He indicated that the newly
graduated nurse is not philosophically, emotionally, or
educationally prepared by the teacher to function in the
The nurse is not prepared by the educator about
hosp~tal.
I
a realistic hospital environment.
Brody emphasized that a
nurse must be taught the differences between the classroom
and the hospital or the nursing shortage will continue (17).
Gail Warden, executive vice president of the
American Hospital Association, noted that one of the vital
factors in keeping and attracting nurses related to
decision-making responsibility or lack of it (21:8).
Barbara Donaho, a member of the National Commission of
Nursing, agreed.
I happen to believe that attrition is related
directly to a nurse being able to influence the
environment and define nursing practice within it.
Nurses are given increased patient care responsibilities, but we haven't given them a corresponding
increase in decision-making responsibilities.
(73:16)
Another possible cause of the shortage is the
doctor/nurse relationship.
In the past, the nurse learned
her trade at the bedside and served as the handmaiden of
the doctor.
The nursing profession has changed.
Nurses do
not see themselves as handmaidens but as colleagues of the
doctors.
Today's nurse is educated.
bachelor's and master's degrees.
Many receive
With increased education
and technology, the nurse's responsibility has greatly
19
increased.
A nurse is held in
hi~h
esteem.
many doctors do not see nurses in this light.
Unfortunately,
A conflict
occurs between these two professionals who each desire an
upheld status.
The nurse is still considered as a servant
or appendage of the doctor (75).
As society changes, the attitudes of the nurse
change.
The equal rights movement has stimulated women not
to be content with the subservient attitude doctors have
toward them.
Nurses want to do their jobs well but they
also want to be recognized for their efforts and respected
for their abilities.
According to Steck, the nursing
shortage is an effective demonstration of positive changes
in the status of women.
Steck further indicated that,
in the health care system, traditional
male and female roles have become institutionalized;
the female nurse is subordinate to the male
physician.
(58:303)
In an effort to improve the nursing profession, nursing
programs are trying to produce graduates who are "knowledge
oriented, autonomous, self-actualizing professionals
prepared to be decision-makers in the administration of
personalized patient care.''
This position has, however,
produced social conflicts for the nurse.
The nurse trying
to resolve this conflict will eventually transfer to a
nonhospital position, thus the shortage of qualified
permanent nursing staff in the hospital (58).
20
Many doctors resent this new attitude of nurses.
According to Laura Payne, administrative supervisor of
nursing at Lamonte Hospital, many doctors "yell" at nurses
without cause.
Some nurses cower and apologize, but a lot
of nurses take a stand by using the knowledge that they
have attained through their education and the time spent
with the patient to justify the situation.
When conflicts
of this type occur, the hospital will usually side with the
doctor for, after all, it is the doctor who provides
patients for the hospital.
According to a survey by Registered Nurse Magazine,
three out of four doctors regard nurses as their
assistants--and nothing more.
The survey found that
doctors thought registered nurses could be replaced by
licensed practical nurses, aides, or practical aides in
many situations.
Less than one third of the doctors
surveyed felt that nurses were indispensable.
Seventy-
eight percent surveyed thought that nurses had sufficient
authority but that nurses were overworked and underpaid.
Eight out of ten doctors surveyed were opposed to the idea
of unionization of nurses.
The younger the doctor, the
more likely he/she was to see the nurse as a colleague.
When asked how nursing could be improved, one third called
for more educational programs and one fourth called for
more tender loving care (36).
21
A third possible cause of the nursing shortage in
the hospital revolves around hospital working conditions,
lack of job satisfaction, and incompatible work groups.
According to Jo Perry of the Regional Hospital
Administration, nurses leave their jobs because they have
come to see nursing as a dead-end job.
A nurse seems to
reach her point of fulfillment which is oftentimes short of
her expectations.
One possible reason for this attitude is
that nurses have to perform many non-nursing type functions.
Nurses have cited other reasons for job dissatisfaction as
inability to make full use of abilities, little opportunity
to learn new things, and overwork (see Figure 1).
The nurses also cited horrible evening and weekend
hours as dissatisfying.
The problem of night staffing is
one of the most perplexing situations to the nursing
administrator.
Weiss, Soblech, and Sauer of Saint Joseph
Medical Center indicated that staffing the night shift is
made more difficult by the following factors:
(1) lack of
enough sleep by night shift nurses; (2) insufficient
numbers of experienced staff for new nurses to learn from
which creates low morale and difficulty in convincing new
graduates to work the night shift; (3) constant pressure
on the nurse from spouse and family to get off night shift;
(4) inability to obtain registry nurses for night shift
duty;
(5) increased probability for error, efficiency,
Sense of achievement
1.-- - - - - - - I 17%
Recognition/appreciation
6%
45%
Knowing you've helped others
Intellectual stimulation
I·
:J 23%
-
Educational opportunities
Fellowship with colleagues
,---_________
1 12%
34%
24%
Income
26%
Opportunity to be innovative
Opportunity to choose own hours
35%
Opportunity for advancement
Chance to be a leader
41%
J
1
14%
Figure 1
How Well Does Your Present Job Meet Your Needs?
(Percentage Rating Poorly) (46:4A)
tiJ
tiJ
23
overtime, and sick time by inexperienced and tired night
shift personnel; and (6) decreasing morale of long-time
dependable night nurses because of the above circumstances.
Another factor in job dissatisfaction is the lack
of coordination and cooperation in a unit.
Nurses, also,
find that working hard does not always produce the desired
outcome.
A recent survey of five large hospitals found
that sometimes the only response a nurse would get was the
self-satisfaction of a job well done.
In the area of
supervisory staff support, it was reported that "not much
happens--either positively or negatively."
(30)
The job of a nurse is one filled with split-second
life and death decisions.
The nurse must respond to these
events quickly and appropriately.
stress.
This type of work causes
Johnson's study showed that 45 to 50 percent of
the nurses are dissatisfied with the amount of tension on
the job.
Sarah Miller of Rios Hospital said that the major
stress in the hospital is from "loss, death, and illness."
(73)
This stress has been coined "burn-out" and is defined
as the physical and emotional wear and tear from constant
intense pressure of caring for the critically ill (38).
The constant turnover of the nursing staff also adds to
stress on the job.
Floors become understaffed.
nurses are floated to other units.
Permanent
Nurses are required to
work with supplemental personnel who are unfamiliar with
24
the patient and hospital procedures.
With the increase in medical technology, nursing
tasks are becoming more specialized.
Some nurses feel that
their job is becoming task-oriented rather than directly
patient-related (8).
The following highlights this issue:
Specialization is changing the task and social
structures of many hospitals and it is affecting the
worker who is attempting to derive some personal
development through his work rol~s.
A system characterized by little direct supervision, increasing
specialization, and organized around a professional
model for carrying out its work roles, is not conducive to satisfy workers' personal needs for development.
Specialization increases repetition. When
specialized jobs confine a worker to operate a single
piece of equipment, or performing a single technique
such as .
. passing medications he obtains little
sense of involvement in his job and only vague appreciation and understanding of any contribution he has
made toward improving the patient's condition.
Performing these specialized roles without any supervision means that a worker is able to achieve only a
small level of visibility; he is seldom praised for
an excellent performance, seldom criticized for a
poor one.
Specialization has turned most jobs into
a rather routine performance which fails to challenge
the individual since much of the personal judgment
and initiative has been removed.
The very qualities
which are conducive to job involvement are now denied
to many allied health personnel.
(28:39-40)
A fourth cause for the nursing shortage is the
relationship between the nurse and the administrative
staff.
Nurses complain of lack of communication as a big
reason for leaving the hospital.
In the Johnson study,
registered nurses complain in the exit interviews that they
received "too much criticism instead of support from the
head nurse."
According to Johnson, only about 31 percent
25
of registered nurses were certain of their supervisor's
expectations and 48 percent stated that they often had a
hard time getting feedback either positively or negatively
regarding their work (30).
Some hospitals now offer
meetings between the hospital administration and the
nursing staff.
Unfortunately, according to Johnson, 67
percent of the nurses believe that these meetings have
little or no influence over nursing staff policies.
It appears that inadequate pay and benefits might
be another reason for the nursing shortage.
As compared to
what secretaries, supermarket checkers, bus drivers, and
street cleaners get paid, nurses would say yes.
(Nursing
salaries were up 14 percent from 1977 to 1979, which was
less than the cost of living which increased 16.8 percent.)
Nurses do, after all, deal with life and death
responsibility (29).
However, according to two studies,
pay dissatisfaction does not appear to be a root cause of
nursing turnover:
1.
Two studies showed that as salary levels
increased, nurses preferred to cut back the total number of
working hours while still maintaining the same level of
income (16).
2.
In 1975, nurses went on strike in California
not to demand higher wages but to demand changes in
staffing patterns and nursejpatient ratios (76).
26
Registries
The registry:
Is it part of the nursing shortage
problem or is it part of the solution?
Many hospital
administrators feel that the registry is the perpetrator
of the current shortage situation in the hospital while
providing supplemental personnel of questionable quality.
The registry agencies disagree and feel that their services
are a result, not the cause, of the shortage.
The registry, or supplemental staffing agencies,
came into existence at a time when hospitals had the need
for quick temporary help to fill spaces created by sick
days and vacations.
The agency is the legal employer of
the nurses whom they recruit, interview, and place in
institutions.
Some of the reasons nurses give for joining
registries include the promise of "higher pay, flexible
hours, and not having to deal with the myriad of rules,
regulations, and politics."
(43:68)
Many nurses are
unhappy with weekend and evening shifts.
registry enables them to choose hours.
Working for a
Recent surveys
indicate that as many as half the nurses who are now
working for agencies in hospitals would leave nursing
entirely if the supplemental nursing service was eliminated
(14).
Many important administrators feel that the
registries represent an important, cost-effective resource
'
.
27
(see Figure 2).
Registry personnel are readily available,
enable a hospital to maintain adequate staffing levels, and
are good for coverage on weekends, vacations, or during
staff illness.
In California, it is reported that between
600 and 800 such agencies exist.
Their growth has been
spurred by a need in the community and money available to
pay for this need.
One hospital in southern California reported that
"its 1980 expenditures for supplemental staff totaled $1.4
million, with expectations of spending $2 million in 1981."
(43:66)
There are complaints that registry personnel are
poorly screened and often sent on assignments for which
they lack the necessary qualifications.
The registry staff
itself is often unaware of health care system regulations.
(Of twelve agencies surveyed by a California surveyor's
agency, only eight asked to see a nurse's CPR card.
Title
22 of the California State Administrative Code requires
nursing personnel to possess a current CPR card to work in
a hospital.)
(44)
This places an added burden on the
nursing administrator to rescreen the agency nurse prior to
putting her on a unit.
Adding an agency nurse also
contributes to the lack of continuity of care in a unit.
The agency nurse is unfamiliar with the patients' needs and
the routines and procedures of the hospital.
There is
usually not enough time for a planned orientation to the
I.
Responsibilities for Selection
Shared
Ehployer
Utilizer
Nurse
Employer and utilizer
Select registered nurse
employee, utilizing the
following:
Verify current RN
license in state.
Be aware of selection
process used by
employer.
Maintain current
licensure.
- Personal interview
criteria
Select a reputable
employer.
- Review of education
and experience (Employees with less
than 1-year experience should not be
used in this
capacity).
Arrange for increasin~
experience and maintain
skills required for
practice.
- Skills inventory.
- Competency Testing
(if available).
Maintain certification,
where applicable.
Figure 2
ANA Sets Guidelines for Agency Use (14:71-73)
1:\:)
00
Shared
Employer
Utilizer
Nurse
Employer and utilizer
- Identification of
certification, continuing education credit;
staff development program(s); special preparation, such as
critical care.
Maintain professional
liability insurance.
- Health care statement
meeting legal requirements of area.
Engage in self -care and
health maintenance
activities.
Review with prospective
employee
- Policies
Provide the facility's
pertinent practices
and job descriptions
to the employer.
Obtain satisfactory
information to function
in setting.
- Practices
- Job description
delineating the functions,
responsibilities, and
qualifications of the
position.
Figure 2 (continued)
1\j
CD
Shared
Employer
Utilizer
Nurse
Employer and utilizer
Provide professional
acceptance reference
checks
II.
Responsibilities for orientation
Include in orientation
review of utilizing
organization's policies
and practices, job
description, and brief
philosophy of nursing
services.
Prepare information and
present applicable policies and practices of
institution.
Prepare staff for
appropriate utilization of supplemental
nursing staff.
Plan on-site orientation
(for accountability for
content).
Include in on-site
orientation the
following pertinent
key factors:
-Philosophy of nursing
service.
-Established criteria/
standards for nursing
practice and related
procedures on the
assigned nursing unit.
Be familiar with and
accountable for functions
within the job description.
Abide by standards of
ethical practice and conduct as defined in the
ANA Code for Nurses.
Utilize recognized standards of nursing practice.
Document the nursing
process.
Figure 2 (continued)
w
0
Shared
Ehployer
Utilizer
Nurse
Employer and utilizer
-Identification of and Adhere to policies and
procedures of utilizer
means of reaching
immediate supervisor.
and employer.
-Patient care emergency
procedures and location of equipment and
supplies.
-Patient identification
system.
-Medication procedures.
-Documentation procedures.
-Location and activation
of fire alann system
and other patient safety
systems, such as injection control program.
-Manner of reporting
unusual incidents or
injuries.
Figure 2 (continued)
c.u
1--'
Shared
Employer
Utilizer
Nurse
Employer and utilizer
III.
Responsibilities for professional development
Encourage supplemental
personnel to maintain and
keep abreast of current
standards of nursing care
through continuing education programs offered
within the nursing and
health care community.
IV.
Keep abreast of changes
in nursing through active
participation in relevant
programs of continuing
education.
Responsibilities for assignment
Maintain and update a
skill inventory available to the utilizer
as a documented tool
of existing education,
experience, and skill.
Indicate in request to
employer specific
skills needed.
Refuse assignment that is
beyond the scope of preparation.
Attempt to match
skill of employee to
needs of patients.
Appear on duty when
assigned.
Complete assignment
according to standards.
Figure 2 (continued)
w
1:\:)
Shared
Fnployer
Utilizer
Nurse
Employer and utilizer
Require that nurses
assigned to special care
areas have documented
education and experience
comparable to that
needed.
Do not assign supple-
mental nursing professional to charge nurse
positions, except in
instances where the
institution knows the
competence of the
individual.
Wherever possible, reassign a nurse to the
same utilizer and the
same unit.
Give priority, in all
cases, to continuity of
assignment.
Figure 2 (continued)
w
w
...
Shared
Utilizer
Employer
Nurse
Employer and utilizer
V.
Responsibilities for evaluation
Establish system for the
evaluation of performance, including the
following:
-System of immediate
feedback to deal
with unacceptable
performance.
-Written evaluation
at regular intervals.
-Review of evaluation
with the nurse.
Maintain record of
performance.
Observe nursing perfor- Evaluate own performance
mance during assignments against standards of
in relation to stated
practice.
standards of care to
provide feedback andjor
immediate counseling.
Assign designated
individuals to coordinate
and monitor the supplemental staffing activities.
Figure 2 (continued)
VJ
~
.,
35
hospital for the agency nurse as well as a problem with
staff morale.
The regular staff often resents having to
work with an agency nurse because it means increased
orientation time, possible floating, or reassignment of the
staff nurse to another unit.
This resentment leads to an
increase in stress levels in the unit.
There is also a problem with accountability with
the agency nurse.
The nursing quality of an agency nurse
is reported to be quite inferior to that of a staff nurse
(13).
However, if an agency nurse exhibits poor nursing
abilities, she can choose to work at another hospital the
following day instead of being accountable for her work.
This leaves the hospital in a poor position because it is
still responsible and accountable to the patient.
Supplementary nurse agencies are trying to prove
that they are a solution rather than the cause of shortage
problems.
Many are experimenting with programs whereby
they contract to provide all the staffing and supervision
of nurses in a unit.
R.N. Nursing Services, Inc., a
Chicago agency, used thirty of its nurses to fill eighteen
positions at Mount Sinai Hospital Medical Center in
Chicago.
This helped Mount Sinai consolidate the bulk of
the hospital's use of temporary nurses in its medical/
surgical unit and turn over its staffing to one agency.
Consequently, Mount Sinai Hospital Medical Center was
36
given the time to recruit permanent nurses for the unit
(32:40).
Similar programs have been introduced by medical
personnel at New Orleans' JoEllen Smith Memorial Hospital
and by Janna at Williamson Memorial Hospital in Fort Myers,
Florida.
Janna has been able to reduce nursing hours per
patient day to five hours from nine hours.
This has saved
Williamson Memorial Hospital (a seventy-four bed hospital)
between $13,000 and $25,000 per month (32:40).
Setting of Project
The following chapter presents a case study which
identifies the costs of not having a permanent nursing
staff in the hospital.
The hospital was a non-identified
southern California full service, 160-bed, general/acute
care hospital.
Chapter 3
METHODOLOGY
Statement of Problem
In the preceding chapters, background information
as to why there is an inadequate supply of nurses in the
hospital was presented.
This lack of nurses has
dramatically influenced the rising cost of health care.
A case study follows that is designed to meet measurable
objectives.
Objectives
The objectives of the case study included:
1.
To simulate a typical acute care general
hospital in southern California as it relates to nursing
units and staff requirements to provide appropriate
patient care.
2.
To analyze the cost of not having a permanent
nursing staff in the simulated hospital.
Definition
Southern California Community Hospital is a 160-bed,
general acute hospital.
It is owned by ABC Hospital
Management, Inc., a publicly held corporation.
The
hospital board is comprised of three company executives,
37
38
the hospital administrator, the chief of the medical staff,
and two members from the community.
The hospital
organization is typical of this size facility with
appropriate levels of management.
There are many competing hospitals in the
geographical area of the Southern California Community
Hospital ranging from small specialty hospitals to large
(more than 400 beds) teaching hospitals.
Due to an excess
number of beds, the Southern California Community Hospital
is unable to average higher than a 70 percent occupancy
level.
Sources of Data and Their Measurement
Although a hypothetical hospital was used in this
case study, the facts and figures were derived from actual
data obtained from the following sources:
1.
Financial statements of an existing 160-bed
facility,
2.
Hospital Council of Southern California wage
and salary surveys,
3.
Variable staffing guides of two proprietary
hospital chains, and
4.
registries.
Information from southern California nurse
39
There are many factors contributing to the census
level in hospitals.
They include, but are not limited to,
1.
Hospital reputation;
2.
Quality of care provided;
3.
Physical plant, including equipment;
4.
Number of active physicians (primarily general
practitioners) on staff;
5.
Time of the year;
6.
Day of the week (census is highest midweek);
7.
Politics (internal and external);
8.
Location of medical office buildings;
9.
Meals being served in the doctor's dining room.
It is the daily census level, combined with the
acuity of patient conditions, which is used to determine
the required level of nursing intervention (staffed hours)
for the next twenty-four hours.
The staffing coordinator
must be aware of all physical, medical, emotional, and
educational needs of the patient.
Analysis
Common practice within hospitals is to staff all
patient areas using what is known as a "variable staffing
guide."
This guide consists of tables of nursing hours
per patient ratios for all levels of nursing care (see
Appendix).
The ratios selected for any particular
40
hospital are dependent upon management philosophy and
community standards.
The ratios must be within the limits
of established guidelines of the Joint Commission on
Accreditation of Hospitals (Joint Commission on
Accreditation of Hospitals Accreditation Manual, 1980).
Chapter 4
RESULTS
The objectives of the case study included:
1.
To simulate a typical acute care general
hospital in southern California as it relates to nursing
units and staff requirements to provide appropriate
patient care.
2.
To analyze the cost of not having a permanent
nursing staff in the simulated hospital.
Findings
A case study was developed in which an acute care
general hospital was simulated.
Data were accumulated
from hospital industry representatives (American Medical
International, Inc.; American Medicorp, Inc.; Hospital
Council of Southern California), thereby assuring a
realistic model.
It was not necessary to recreate the
entire hospital as the study focused primarily on nursing.
Only patient care units, salaries, staffing parameters,
and census levels were required.
This information combined
with data obtained from nurse registries was sufficient to
meet the needs of the second objective of the study~-to
analyze the cost of not having a permanent nursing staff.
41
42
The conservative methodology used to determine the cost
variance due to using a nonpermanent nursing staff
produced the outcome suggested by the review of literature.
As stated previously, Southern California Community
Hospital has 160 beds.
These beds are divided into six
distinct nursing stations:
Surgical I . . . . . . . . . . . . . .
30 beds
Surgical II . . . . . . . . . . . . .
30 beds
Medical I . . . . . . . . . . . . . . .
30 beds
Pediatrics
20 beds
Definitive Observation
Unit . . . . . . . . . . . . . . . . . . .
30 beds
Intensive Care Unit .....
10 beds
Cardiac Care Unit .......
10 beds
Total . . . . . . . . . . . . . . 160 beds
The average daily occupancy for the total hospital
might be 60 percent, but each of the above stations also
has its own level of occupancy.
The percentage of
occupancy ranges from 20 percent to 100 percent.
Southern California Community Hospital, along with
competitors, is unable to employ enough of a permanent
nursing staff to meet daily demands.
Therefore, the
hospital must rely on nurse registries to provide
additional manpower.
There are six registries in the area
which charge the hospital at comparable rates, averaging
43
as shown in Table 3.
Current national averages for registry utilization
is 10 percent days (7:00a.m. to 3:30p.m.), 20 percent
evenings (3:00p.m. to 11:30 p.m.), and 25 percent nights
(11:00 p.m. to 7:30a.m.).
It is even higher in the
intensive care unit/cardiac care unit, averaging 35 percent
evenings and night shifts.
Table 4 shows the current wage structure in effect
at Southern California Community Hospital.
Employees
receive additional benefits (medical insurance, sick pay,
holiday pay, and vacation pay) which equates to an
additional 18 percent of salary if reduced to dollars and
cents.
Given the average daily census per unit and
staffing hours, simple calculations lead to the number of
nursing hours required per day (see Table 5 for daily
requirement).
Not all of the required nursing hours are filled
by registered nurses.
Once again, depending on management
philosophy and community standards, the total number of
required nursing hours is broken down into three categories
of nursing levels:
registered nurse, licensed vocational
nurse/licensed practical nurse, and nurse aide.
Southern
California Community Hospital'currently uses the team
nursing concept which allows for utilization of all three
Table 3
Registry Rates
a
Weekday
Weekend
Position
7-3
3-11
11-7
7-3
RN/Floor
$139.00
17.37
$148.00
18.50
$154.00
19.25
$148.00
18.50
$160.00
20.00
RN/Unit
$168.00
21.00
$172.00
21.50
$179.00
22.37
$172.00
21.50
$182.00
22.74
LVN/Floor
$105.00
13.12
$112.00
14.00
$120.00
15.00
$112.00
14.00
$129.00
16.12
LVN/Unit
$112.00
14.00
$120.00
15.00
$129.00
16.12
$120.00
15.00
$133.00
16.62
Nurse Aide
$ 77.00
9.62
$ 82.00
10.25
$ 92.00
11.50
$ 82.00
10.25
$ 96.00
12.00
3-11/11-7
a $ per shift
$ per hour
fl:>.
fl:>.
Table 4
Hospital Nurse Salaries
Step
Classification
IV
v
9.83
10.33
10.84
9.83
10.33
10.84
11.38
5.87
6.16
6.46
6.79
7.13
Licensed vocational
nurse/unit
6.16
6.46
6.79
7.13
7.49
Nurse aide
4.26
4.47
4.70
4.93
5.18
I
II
Registered nurse/floor
8.19
9.36
Registered nursejunit
9.36
Licensed vocational
nurse/floor
III
Shift Differential:
Registered nurse:
3 to 11 and 11 to 7 shifts:
additional
Licensed vocational nurse: 3 to 11 and 11 to 7 shifts:
additional
Nurse aide:
3 to 11 and 11 to 7 shifts:
additional
$1.73 per hour
$.72 per hour
$.43 per hour
~
CJl
46
categories in a proper mix depending on patient acuity.
Table 5
Variable Staffing for Hospital Nursing Stations
Station
Staffing Ratio
Surgical I . . . . . . . . . . . . . . . . . . . . . . . .
4.75 hours/patient day
Surgical I I . . . . . . . . . . . . . . . . . . . . . . .
4.75 hours/patient day
Medical I
........................ .
4.75 hours/patient day
Pediatrics . . . . . . . . . . . . . . . . . . . . . . . .
5.10 hours/patient day
Direct Observation
Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.00 hours/patient day
Intensive Care Unit . . . . . . . . . . . . . . . 12.00 hoursjpatient day
Cardiac Care Unit . . . . . . . . . . . . . . . . . 12.00 hoursjpatient day
Table 6 presents a breakdown of nurse hours
required by skill per shift.
The only additional parameter
that comes into play is that registered nurses and licensed
vocational nurses used in the intensive care unit and
cardiac care unit are specially trained and are compensated
at higher rates than registered nurses and licensed
vocational nurses in other units (see tables 7 and 8).
The statistics given indicate hours of nursing
required on a daily basis by shift and skill level.
The
following tables provide the final calculations for
determining the cost of using registry personnel at the
levels previously indicated.
In determining registry
47
p '
Table 6
Daily Requirements--Total Nursing Hours
Station
Beds
Percentage
Census
Occupancy
Nurse
Hours
Surgical I
30
60
18
88.0
Surgical II
30
60
18
88.0
Medical I
30
60
18
88.0
Pediatrics
20
60
12
64.0
Direct Observation
Unit
30
60
18
144.0
Intensive Care Unit
10
60
6
72.0
Cardiac Care Unit
20
60
6
72.0
160
60
96
608.0
Total
utilization, the number of hours correspond to the nearest
one half shift (four hours) as is normal practice (see
Table 9).
As most of the nursing staff at the hospital is
being compensated on steps 3, 4, or 5 of their respective
scales, the fourth step wage rate was used for calculations
in Table 9.
The cost per day for supplemental nurses is
$859.20.
Annualized, this amounts to $313,608.00.
Payroll
costs for Southern California Community Hospital (not
considering vacations and sick or holiday pay) for the
Table 7
Daily Requirements--Nursing Hours by Shift and Nursing Level
Station
Total
Nurse
Hours
LVNa
Registered Nurse
Day
Even
Day
Night
Nurse Aide
Even Night
Day
Even Night
Surgical I
88
16
16
8
16
8
8
8
8
-
Surgical II
88
16
16
8
16
8
8
8
8
-
Medical I
88
16
16
8
16
8
8
8
8
-
Pediatrics
64
16
8
8
8
8
8
-
8
-
144
32
16
16
16
16
8
16
16
8
472
96
72
48
72
48
40
40
48
8
Intensive Care Unit
72
24
16
16
8
8
-
-
-
-
Cardiac Care Unit
72
24
16
16
8
8
-
-
-
-
Total Unit
144
48
32
32
16
16
-
-
-
-
Hospital Total
616
Direct Observation
Unit
Total Floor
~----------
-~--------
--·
-·
- - - ---
--
----
--
----
-
-
-
--------
-~--
--
aLVN = Licensed Vocational Nurse
H:::.
(X)
Table 8
Registry Utilization
--------
Days
(J)
H
(J)
b£)
b£)
r-i[f1
Nights
Evenings
(J)
Cill»
Position
-
~H
~~
(J) rJ1
:>,
Cil:>,
H
~
rJ1 rJ1
0·r-1
H b£l
·r-1 H
b£l::S
E-il:J::
~r:r::
r:r::::r::
Registered Nurse
96
10
Licensed Vocational Nurse
72
Nurse Aide
r-irJl
H
~H
~~
(J) rJ1
b£)
:>,
Cill»
H
~
rJ1 rJ1
~r:r::
t:c:::r::
16
48
25
12
20
8
40
25
12
48
20
8
8
25
-
8
32
35
12
32
35
12
-
16
35
8
-
-
-
~r:r::
r:r::::r::
8
72
20
10
8
48
40
10
4
Registered Nurse
48
10
Licensed Vocational Nurse
16
10
(J)
(J)
(J)
rJ1 rJ1
E-il:J::
E-i::C::
0 0
~
·r-1 H
b£l::S
·r-1 H
b£l::S
~::s
:>,
H
C)·r-1
Hb£l
0·r-1
Hb£l
Cil
r-irJl
~H
~~
(J) rJ1
0
Cil
~::s
0 0
(J)
(J)
(J)
0
Cil
H
~::s
0 0
(J) (J)
(J)
0
Floor Nursing:
Unit Nursing:
--
-
------
---·
-·
----
-
H::..
c:o
Table 9
Calculations for Cost per Day for Supplemental Nurses
-Nurse Category
Shift
Registry
Hours
Hospital
Salary
per
Hour
Registry
Charge
per
Hour
Registry
Hourly
Cost
Variance
Daily
Registry
Cost
Floor
Registered Nurse
Days
Evenings
Nights
8
16
12
$10.33
12.06
12.06
$17.37
18.50
19.25
$ 7.04
6.44
7.19
$ 56.32
103.04
86.28
Licensed Vocational
Nurse
Days
Evenings
Nights
8
8
12
6.79
7.51
7.51
13.12
14.00
15.00
6.33
6.49
7.49
50.64
51.92
87.88
Nurse Aide
Days
Evenings
Nights
4
8
4.93
5.36
5.36
9.62
10.25
11.25
4.69
4.89
6.14
18.76
39.12
-
CJl
0
Table 9 (continued)
Nurse Category
Shift
Registry
Hours
Hospital
Salary
per
Hour
Registry
Charge
per
Hour
Registry
Hourly
Cost
Variance
Daily
Registry
Cost
Unit
Registered Nurse
Days
Evenings
Nights
8
12
12
$10.84
12.57
12.57
$21.00
21.50
22.37
$10.15
8.93
9.80
$ 81.28
107.16
117.60
Licensed Vocational
Nurse
Days
Evenings
Nights
8
7.13
7.85
7.85
14.00
15.00
16.12
6.87
7.15
8.27
57.20
Hospital Total
116
$859.20
c.n
......
52
entire year would be $1.4 million, if staffed by permanent
nurses.
Limitations
This project was prepared in view of the following
limitations:
1.
Normally premium pay is charged the hospital
for weekends and holidays.
During Christmas and Easter
seasons, as well as the summer months, the percentage of
registry utilization increases.
Particularly in southern
California, utilization increases as much as 30 percent
above the normal.
2.
As indicated earlier, Southern California
Community Hospital is a proprietary hospital and there is
a tendency to have tighter staffing standards than in a
nonprofit hospital.
Whereas the study used 4.75 hours/
patient day on the medical/surgical nursing stations, it is
just as common to see 5.5 hours/patient day used.
Obviously, the higher the nursing per patient ratio, the
greater the need for supplemental nurses and increased
cost.
3.
Southern California Community Hospital used the
team nursing concept.
Many hospitals, even with the
nursing shortage, are committing to primary nursing which
uses registered nurses almost exclusively.
This change
53
will lead to even higher utilization of registries as the
demand for registered nurses increases.
4.
The effect of nurse registry personnel on
ancillary services (i.e., laboratory, radiology, cardiopulmonary) due to diminished efficiency with respect to
order writing and charting is beyond the scope of this
study.
Chapter 5
CONCLUSIONS, RECOMMENDATIONS, AND SUMMARY
The following chapter presents conclusions reached
through the research, recommendations to increase the
permanent nursing staff in hospitals and health care
agencies, and a summary of the project.
Hospitals and health care agencies have been
experimenting with a number of different programs to
increase the number of permanent nurses on the hospital
staff.
Historical solutions to staffing problems have
been (1) dependency on the new graduates to be oriented
in time to carry through to the next graduating class;
(2) loyalty and willingness of personnel to work overtime,
double shifts, and extra days if required;
(3)
experimentation with ten- or twelve-hour shifts; (4)
enhancement of benefits and salaries; and (5) hiring of
nurse recruiters (66).
Saint Joseph Medical Center in Burbank, California,
is among the hospitals successful in their nurse staffing
programs.
Saint Joseph Medical Center has been totally
free of registry use since October 1, 1979, and was able
to sustain optimal staffing for its high hospital
occupancy, which during the first quarter of 1980 averaged
54
55
93 percent.
Some of the retention factors that they are
using include special per diem program, alternate weekends
off, and four-shift work weeks on nights (3) (see
Figure 3).
Rush-Presbyterian/Saint Luke's Medical Center in
Chicago is using a "levels of practice" system to try to
increase job satisfaction among their nurses, thereby
improving nurse retention and motivation to excellence.
The levels of practice system rewards nurses who remain in
the direct care area.
In addition to providing
professional advancement, increased status and financial
gains for achievement in clinical practice, the system also
provides job descriptions which aid management in
orientation, progress inventory, and development of staff.
In a questionnaire of staff nurses, 50 percent gave the
levels of practice as one reason for staying at the
hospital.
Other hospitals have experimented with flexible
time schedules to focus in on the nurse retention problem.
In an effort to solve the weekend scheduling problem,
hospitals have set up 3-day/36-hour weeks, 4-day/40-hour
weeks, and even 7-dayj70-hour weeks with 7 days on and
7 days off.
However, this latter program has led to loss
of continuity with patient and hospital by the nurse.
According to Hatfield, president of Hospital Management
56
APPETIZERS
Clinical nursing experience for 5 colleges
associate RN degree
baccalaureate RN degree
licensed vocational nurse
- Training for other nursing disciplines
ward secretaries
monitor technicians
nursing assistants
emergency medicine technicians
- Comprehensive new graduate
internship program
ENTREES
No rotating shifts
Every other weekend off
Professional recognition by peers
Quality management direction and interaction
Appropriate nurse-physician relationship
Ancillary departments around the clock
Clinical instructors available 24 hours a day
Hot food on all three shifts
Free parking
CPR Certification
SIDE DISHES
Special per diem program
Four shift work week on nights
Primary care on several units
12-hour shifts in emergency department
All RN-staffed intensive and sub-intensive care units
Critical care classes
Stress management seminar
CEU workshops
Attendance at 3-time weekly medical
conferences
Figure 3
Gourmet Menu for Retention (66:23)
57
Figure 3 (continued)
DESSERTS
Clinical ladder
Formal education B.S. degree offered at SJMC
Tuition reimbursement
Job enrichment courses
Supervisory training programs
Substantial reimbursement for unused sick time
Eligible for benefits from day 1
Vacation eligibility after 6 months
Participation in medical staff and nursing committees
Resources Corporation, flexible time schedules should be
tailored to each unit and the nurses on that unit (33).
Other hospitals have changed to a primary nursing
approach to patient care to make the nursing job more
challenging and rewarding.
Gottlieb Memorial uses the
care method of nursing wherein the nurse is responsible
for total patient care for her shift (33).
The Los Angeles Unified School District is
experimenting with a fully accredited high-school
vocational nursing curriculum which gives the graduates
enough instruction to pass California's registered
vocational nurse licensing examination.
The program hopes
to bridge the shortage gap in the future by motivating the
vocational nursing students to further their education at
two- and four-year colleges.
The Hospital Council of Southern California is
involved in ten separate nursing school expansion programs
58
to help generate 300 additional registered nurse students
per year in southern California.
Groups of local hospitals
are funding additional nursing instructors which enables
nursing schools to recruit additional students for their
programs.
It is anticipated that licensed vocational
nurses will enter associate degree programs and become
eligible to sit for the registered nurse board examinations,
thus increasing the supply of registered nurses.
It was hoped that an influx of foreign nurses might
add to the supply of registered nurses.
However, between
1969 and 1977, of 75,000 foreign nurses entering on
foreign visas, fewer than 20 percent of them have been able
to pass state licensing examinations.
Regulations have
been proposed requiring foreign nurses to pass an
examination overseas as a prerequisite to obtaining an
American visa.
Many hospitals are currently looking for solutions
to use to keep a permanent nursing staff.
Five hospitals
recently interviewed by the Hospital Council of Southern
California gave the following list as major elements that
they used to plan nurse retention programs (45).
1.
Support of medical staff
2.
Support of nursing staff
3.
Close some beds
4.
Establish per diem pool
59
5.
Every other weekend off
6.
Well organized orientation programs
7.
Flexible scheduling
8.
Care team
9.
Cross training
10.
All registered nursing staff or primary nursing
11.
Close contact with nursing administration
12.
Staff surveys
13.
Regular staff meetings
14.
Specific time frame for the plan of action
Conclusions
An acute care hospital was simulated to provide
data on nursing units and staff required to provide
appropriate patient care.
The cost of not having a
permanent nursing staff in the hospital was found to be
22 percent more than if the hospital had a permanent staff.
Hospital administrations have tried a myriad of
approaches to solve the nursing shortage problem from the
hiring of nurse recruiters to flexible time schedules.
While some hospitals have learned to cope with the
problems of the shortage, others have not.
It is necessary
for hospital management to become aware of and deal
appropriately with the causes of the problem.
As health
care shifts toward preventative care from curative care,
60
so must the philosophy of managing the nursing shortage.
The hospital cannot afford to perpetuate this situation.
If today's nurse does not encounter a satisfying work
environment, she will not choose to work in the hospital.
Recommendations
Due to a limited supply of nurses and an increased
demand by hospitals for nursing staff, the registered nurse
is able to find a job in almost any community without
difficulty.
It is up to the hospital administration to
develop methods to hire and retain a permanent nursing
staff at its hospital.
It is difficult to give one
solution to this problem; however, several recommendations
may be offered whereby an administrator can begin to
develop his/her own program.
1.
The administration must become more responsive
to the needs of its nursing staff through enhanced
communication, visibility, and support.
2.
The administration should try to develop a
feeling of teamwork between the doctors and nurses, the
nurses and administration, and the nurses and ancillary
departments.
This would increase communication, decrease
stress, and eventually improve job satisfaction.
3.
Benefits and pay should be made competitive
with other hospitals in the area and other industries.
61
Benefits such as alternative shift options, wage
differentials for undesirable shifts, and child care could
be offered to the nurse.
4.
skills.
The nurse needs the opportunity to utilize her
A behavior pattern study showed that "those whose
values are clear tend to be positive, enthusiastic and
proud."
(31:6)
The hospital could begin a career
development program whereby a nurse could set her goals,
identify her needs, and obtain counseling and guidance.
This program could help a nurse clarify her values in life
and thus become more satisfied with her job.
5.
Reality shock could be reduced through the use
of registered nurses for patient care only and the
delegation of non-nursing duties to non-nursing personnel.
6.
It has been suggested that a management
contract between nurse and administration could clarify
job objectives.
There appears to be a need for this in
the hospital because "the dualism of two formal management
subsystems (administration and doctor) operating in a
hospital creates a diffuse and complex system that often
leaves critical objectives unstated."
( 3:45)
It is
important that an employee of a hospital is cognizant of
the objectives of the organization.
7.
A concerted effort to educate the government
about the shortage of nurses should be made by the health
62
care community.
This might lead to more funding for nurse
education programs.
8.
Medical and nursing schools should try to
educate their students about doctors and nurses,
respectively.
9.
This would lead to better communications.
Nursing schools should educate their students
about the realities of hospital conditions as compared with
academic settings.
Summary
An acute nursing shortage has created problems for
the hospital industry with respect to quality of care and
the cost of delivering that care.
It was the purpose of
this project, through a review of literature and a case
study, to (1) provide an overview of nursing,
(2) identify
the causes of the nursing shortage, (3) quantify the costs
associated with this shortage, and (4) offer possible
recommendations to this problem.
Many factors contribute to the nursing shortage,
including, but not limited to, (1) unmet job expectations
by the nurse, (2) conflicts between doctor and nurse, (3)
poor hospital working conditions, (4) unsatisfactory
relationships between the nurse and administrative staff,
and (5) limited opportunity for career growth.
63
The emergency of registries, or supplemental staff
agencies, seems to be a part of the problem as well as a
solution.
This project demonstrated that reliance upon
registries to fill voids in permanent nursing staff is
both costly and reduces quality of care.
Hospital administrators have tried a myriad of
approaches to solve the nursing shortage problem from the
hiring of nurse recruiters to flexible time schedules.
While some hospitals have learned to cope with the problems
of the shortage, others are overwhelmed.
It is necessary
for hospital management to give more attention to and deal
appropriately with the causes of the problem and not simply
respond to the problem after it develops.
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64
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APPENDIX
72
VARIABLE STAFFING GUIDE FOR MEDICAL/SURGICAL WINGS
(for 4.00 WHPD)
Daily Wing Staffing
Number of
Filled
Beds
1a
2b
20
19
18
17
16
15
14
13
12
11
10
5
5
4
4
3
3
3
3
2
2
2
3
3
3
3
3
3
3
2
2
2
2
9
8
7
6
5
4
3
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
aFirst shift (45%)
Total Staff
WHPD
3c
Daily
Weekly
2
10
10
9
9
8
8
7
7
6
6
6
14.0
14.0
12.6
12.6
11.2
11.2
9.8
9.8
8.4
8.4
8.4
4.00
4.21
4.00
4.24
4.00
4.27
4.00
4.31
4.00
4.36
4.80
6
6
6
6
6
6
6
6
6
8.4
8.4
8.4
8.4
8.4
8.4
8.4
8.4
8.4
5.33
6.00
6.86
8.00
9.60
12.00
16.00
24.00
48.00
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
cThird shift (20%)
bSecond shift (35%)
'I
w
VARIABLE STAFFING GUIDE FOR MEDICAL/SURGICAL WINGS
(for 4.25 WHPD)
Total Staff
Number of
Filled
Beds
Daily Wing Staffing
1a
2b
3c
Daily
Weekly
20
19
18
17
16
15
14
13
12
11
10
5
5
5
4
4
3
3
3
2
2
2
4
3
3
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
11
10
10
9
9
8
7
7
6
6
6
15.4
14.0
14.0
12.6
12.6
11.6
9.8
9.8
8.4
8.4
8.4
4.40
4.21
4.44
4.24
4.50
4.27
4.00
4.31
4.00
4.36
4.80
9
8
7
6
5
4
3
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
6
6
6
6
6
6
6
6
6
8.4
8.4
8.4
8.4
8.4
8.4
8.4
8.4
8.4
5.33
6.00
6.86
8.00
9.60
12.00
16.00
24.00
48.00
aFirst shift (45%)
WHPD
cThird shift (20%)
bSecond shift (35%)
.....:]
~
VARIABLE STAFFING GUIDE FOR MEDICAL/SURGICAL WINGS
(for 4.50 WHPD)
Number of
Filled
Beds
Daily Wing Staffing
Total Staff
WHPD
1a
2b
3c
Daily
Weekly
20
19
18
17
16
15
14
13
12
11
10
5
5
5
5
4
3
3
3
3
2
2
4
4
3
3
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
11
11
10
10
9
8
8
7
7
6
6
15.4
15.4
14.0
14.0
12.6
11.2
11.2
9.8
9.8
8.4
8.4
4.40
4.63
4.44
4.71
4.50
4.27
4.57
4.31
4.67
4.36
4.80
9
8
7
6
5
4
3
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
6
6
6
6
6
6
6
6
6
8.4
8.4
8.4
8.4
8.4
8.4
8.4
8.4
8.4
5.33
6.00
6.86
8.00
9.60
12.00
16.00
24.00
48.00
aFirst shift (45%)
cThird shift (20%)
bSecond shift (35%)
....;J
c.n
VARIABLE STAFFING GUIDE FOR MEDICAL/SURGICAL WINGS
(for 4.75 WHPD)
Number of
Filled
Beds
Total Staff
Daily Wing Staffing
,.
1a
2b
3c
WHPD
Daily
Weekly
--
20
19
18
17
16
15
14
13
12
11
10
5
5
5
5
5
4
3
3
3
3
2
4
4
4
3
3
3
3
3
2
2
2
3
2
2
2
2
2
2
2
2
2
2
12
11
11
10
10
9
8
8
7
7
6
16.8
15.4
15.4
14.0
14.0
12.6
11.2
11.2
9.8
9.8
8.4
4.80
4.63
4.89
4.71
5.00
4.80
4.57
4.92
4.67
5.00
4.80
9
8
7
6
5
4
3
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
6
6
6
6
6
6
6
6
6
8.4
8.4
8.4
8.4
8.4
8.4
8.4
8.4
8.4
5.33
6.00
6.86
8.00
9.60
12.00
16.00
24.00
48.00
aFirst shift (45%)
cThird shift (20%)
bSecond shift (35%)
.....:]
C))
VARIABLE STAFFING GUIDE FOR NURSING/PEDIATRICS
(for 5.10 WHPD)
Number of
Filled
Beds
Total Staff
Daily Wing Staffing
WHPD
Shift 1
Shift 2
Shift 3
Daily
Weekly
30
29
28
27
26
25
24
23
22
21
20
9
8
8
8
8
7
7
7
6
6
6
6
6
6
6
6
6
5
5
5
4
4
4
4
4
3
19
18
18
17
17
16
15
15
14
13
13
26.6
25.2
25.2
24.1
23.8
22.4
21.0
21.0
19.6
18.2
18.2
5.06
4.96
5.14
5.10
5.23
5.12
5.00
5.09
4.95
5.20
5.20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
5
5
5
5
4
3
3
3
2
2
2
2
2
4
4
4
3
3
3
3
3
2
2
2
2
2
2
3
2
2
2
2
2
2
2
2
2
2
2
2
2
12
11
11
10
10
9
8
8
7
6
6
5
5
5
16.8
15.4
15.4
14.0
14.0
12.6
11.2
11.2
9.8
8.4
8.4
7.0
7.0
7.0
5.05
4.88
5.17
5.00
5.33
5.14
4.92
5.33
5.09
4.80
5.33
5.00
5.71
6.67
3
3
3
3
3
3
3
.....;)
....:]
VARIABLE STAFFING GUIDE FOR DIRECT OBSERVATION UNIT
(for 8.00 WHPD)
Number of
Filled
Beds
Daily Wing Staffing
Total Staff
WHPD
Shift 1
Shift 2
20
19
18
17
16
15
14
13
12
11
10
9
9
8
8
7
7
6
6
5
5
5
7
6
6
6
6
5
5
4
4
4
3
9
8
7
6
5
4
3
2
1
4
3
2
2
2
2
2
2
2
3
3
2
2
2
2
2
2
2
Shift 3
Daily
Weekly
4
4
4
3
3
3
3
3
3
2
2
20
19
18
17
16
15
14
13
12
11
10
28.0
26.6
25.2
23.8
22.4
21.0
19.6
18.2
16.8
15.4
14.0
8.00
8.00
8.00
8.00
8.00
8.00
8.00
8.00
8.00
8.00
8.00
2
2
2
2
2
2
2
2
2
9
8
7
6
6
6
6
6
6
12.6
11.2
9.8
8.4
8.4
8.4
8.4
8.4
8.4
8.00
8.00
8.00
8.00
9.00
12.00
16.00
24.00
48.00
...;]
00
VARIABLE STAFFING GUIDE FOR INTENSIVE CARE UNIT
(for 12.0 WHPD)
Number of
Filled
Beds
Total Staff
Daily Wing Staffing
WHPD
Shift 1
Shift 2
Shift 3
Daily
Weekly
15
14
13
12
11
10
10
10
9
8
8
7
8
7
7
6
6
5
5
4
4
4
3
3
23
21
20
18
17
15
32.2
29.4
28.0
25.2
23.8
21.0
12.26
12.00
12.30
12.00
12.36
12.00
9
8
7
6
5
4
3
2
1
6
5
5
4
3
2
2
2
2
5
4
4
3
3
2
2
2
2
3
3
2
2
2
2
2
2
2
14
12
11
9
8
6
6
6
6
19.6
16.8
15.4
12.6
11.2
8.4
8.4
8.4
8.4
12.44
12.00
12.57
12.00
12.80
12.00
16.00
24.00
48.00
--l
co
VARIABLE STAFFING GUIDE FOR CORONARY CARE UNIT
(for 12.0 WHPD)
Number of
Filled
Beds
Total Staff
Daily Wing Staffing
WHPD
Shift 3
Daily
Weekly
Shift 1
Shift 2
15
14
13
12
11
10
10
10
9
8
8
7
8
7
7
6
6
5
5
4
4
4
3
3
23
21
20
18
17
15
32.2
29.4
28.0
25.2
23.8
21.0
12.26
12.00
12.30
12.00
12.36
12.00
9
8
7
6
5
4
3
2
1
6
5
5
4
3
2
2
2
2
5
4
4
3
3
2
2
2
2
3
3
2
2
2
2
2
2
2
14
12
11
9
8
6
6
6
6
19.6
16.8
15.4
12.6
11.2
8.4
8.4
8.4
8.4
12.44
12.00
12.57
12.00
12.80
12.00
16.00
24.00
48.00
00
0