VONL Nursing Task Force Members
Kathy Anderson, Vice
President of Patient Care Services
Brattleboro Memorial Hospital
Ellen Ceppetelli, Associate Professor
University of Vermont
Jane Hayward, Vice President of Patient Care Services
Gifford Medical Center
Toni Kaeding
University of Vermont
Jill Lord, Director of Patient Care Services
Mt. Ascutney Hospital and Health Center
Pat Menchini, Director of Nursing Programs
Vermont Technical College
Susan Nicholls, Nurse Coordinator of Surgical Services and ER
Gifford Medical Center
Roseanne Palmer, Director of Inpatient Services
Central Vermont Medical Center
Helen Spring, Vice
President of Patient Care Services
Central Vermont Medical Center
VAHHS Staff:
Lucie Garand, Executive
Assistant
Norman E. Wright, President
Current State of Nursing in Vermont
Executive Summary
In summary, a health care policy leader was recently
quoted as saying, "nurses are old, tired, and underpaid. They are taking care of
your mother and father and you are next."
Problem Statement: Hospitals and health systems must initiate strategies to attract and
retain qualified nurses to reverse the current trend. These initiatives will exceed the
costs currently allowable in a 2.2% budget increase.
Challenges and recommendations for the Public Oversight Commission:
1. Support wage and benefit packages commensurate with a competitive work force.
• Increase salaries
• Increase support for professional development,
such as career ladders and advancement
programs
2. Support increased budget allocations for education.
• FTE for nursing education departments
• FTE for mentoring novice nurses
• FTE for preceptor programs for specialty nurses
• Continuing education dollars for clinical competencies
3. Recognize that an increased in FTEs is necessary to reverse the current crisis.
• RNs
• LPNs
• LNAs
• Support staff, such as unit secretary and transport staff
• Costs for travel nurses (short term fix)
4. Support dollars budgeted for recruitment efforts.
• Sign on bonus
• Advertising and marketing
• Recruitment
• Out-of-state/international recruitment
Current State of Nursing in Vermont
Report on Nursing
"Report on Nursing in Vermont," prepared by Toni H. Kaeding for the
Vermont Association of Hospitals and Health Systems, Inc. and the Vermont Organization of
Nurse Leaders was intended to gain a statewide perspective of nursing in Vermont. A survey
was distributed to hospitals and health systems (100% return rate), home health (30%
return rate), and long term care (minimal return rate). The results of this survey and
subsequent analysis can be summarized as follows:
I. A nursing shortage appears inevitable, if not already present
• Average age of nurses in Vermont is 45 with 72% of all
nurses over 40 consistent with national trends per
Department of Health and Human Services.
• Vermont schools and colleges are producing 36% fewer nurses
today than 5 years ago.
• RN wages have flattened as per Buerhaus and Straiger in Health
Affairs (1999)
• Per ASHCHRA study of 388 acute care hospitals (1999), it is becoming
increasingly difficultto employ and retain experienced nurses (particularly in specialty
areas, such as critical care,
obstetrics, emergency care, perioperative, and nursing management). Examples of current
expenditures, a Vermont tertiary
hospital has expended approximately $100,000 on advertising
for RNs for the first six months of this fiscal year,
one medium sized hospital in Vermont
anticipates spending $280,000 on Traveling Nurses and one small community hospital
expects to spend $80,000 on Traveling Nurses and $50,000 on advertising in FY 1999.
II. Nurses are working harder
Reality of health care is that hospitals are now a crisis driven
workplace where nurses must immediately respond to an older, more complex, vulnerable
patient.
• Length of stay has decreased in Vermont hospitals from 6.0 days in 1992 to
5.07 days in 1997, which represents a 15.5% decrease in length of stay. This decreased
length of stay has condensed nursing care into fewer hours to assess, care for, teach and
ready the patient for discharge.
• Budgeted RN FTEs were decreased by 3% from 1992 to 1998, while the RN vacancy
rate increased 34% during the same time period. These vacancies are being filled by extra
shifts, overtime costs, and traveling nurses, all solutions that burden nurses and
increase costs.
• LPN FTEs in hospitals has decreased by 20% since 1993.
• Non-clinical work has increased in the form of increased paperwork and
administrative responsibilities. Nursing admission assessments are an example of increased
documentation requirements for one Vermont hospital has increased from 2 pages in 1983 to
4 pages in 1999. Compliance with regulatory requirements to create restraint free
environments have increased documentation from one line in the progress note into an
admission assessment, patient family consent form, Dr. Order form, initial note, and a
flow sheet with documentation every two hours in 1999.
• Increased intensity of work related to the movement to outpatient procedures and
treatments as well as apparent increased acuity of patients.
• Advances in health care technology require nurses to increase their clinical
expertise in patient assessment and interventions.
Why is this Important?
We believe the health status of Vermonters will decrease without an adequate
supply of nurses. The nursing work force is aging without an adequate replacement
strategy. Nurses assume the majority of direct patient care services across all sites on
the continuum.
Nursing care has a significant impact on the cost and quality outcomes
of care:
• A research study designed by Blegen, Goode, and Reed reported in Nursing
Research 1998, entitled "Nurse Staffing and Patient Outcomes," described the
relationship between total hours of nursing care, registered nurse skill mix, and adverse
patient outcomes. This study found "total hours of care from all nursing personnel
were associated directly with the rates of decubiti, complaints, and mortality." The
study also reported that "as the RN proportion increased, the rates of adverse
outcomes decreased up to 87.5%."
• The U.S. Agency for Health Care Policy and Research (AHCPR) has just released a
study of nurse staffing levels and adverse events following surgery in U.S. hospitals.
After analyzing data from 506 hospitals in 10 states, the authors, Kovner, and Gergen,
found that the "fewer full time equivalent registered nurses per in patient day a
hospital has, the greater its incidence of urinary tract infections, pneumonia,
thrombosis, pulmonary congestion, and other lung related problems following surgery."
Nursing Task Force
Key nursing leaders have met over the last year to identify problems and issues
impacting our current situation and to produce a set of recommendations designed to
strengthen and improve the nursing work force in Vermont. The result of this work is
summarized below. This work must continue until strategies and recommendations have been
effectively implemented.
I. Current Issues and Problems
A. Health care practice has significantly changed while methodology of calculating
workload has remained constant which obscures the true picture of resources needed to
accomplish the work. Data found within the current hospital cost reports do not adequately
capture nursing workload related to ambulatory care and observation patients. For example
from August 1998 through March 1999, Northeastern Vermont Regional Hospital averages 65.5
patient days a month which will not be reflected in the hospital's cost report. These days
are primarily observation days. The average does not include the workload generated from
admissions and discharges. It only counts patients in the bed as of midnight census. This
hospital has to assign at least one nurse per shift to care for these patients.
(Attachment 1)
B. The number of nurses in the field will
not be sufficient to meet demand, resulting in a significant nursing shortage within 3
years. Related issues are as follows:
• Novice nurses are less prepared for practicing nursing than in
previous years.
• Average age of nurse is 45, larger numbers leaving work force while enrollments
have decreased by 20% nationally. In Vermont, over the last three years, UVM ADN,
Castleton BSN, and Vermont College ADN programs have all closed or are in the process of a
planned phase out.
• There is a decrease in years of work life related to the
advanced age of students currently entering nursing programs. The age range of VTC nursing
students is 18 to 52.
• Alarming use of traveling nurses to supply need, dramatically increasing costs
and decreasing continuity and efficiency Mt. Ascutney Hospital and Health Center, a small,
rural, community hospital has 4 traveling nurses after 7+ years without travelers. Mt.
Ascutney also experienced a 4-month lag time before ICU travelers were available for hire.
This led the hospital to believe there is an increasing demand for and use of specialty
traveling nurses. This could also be attributed to a shortage of ICU nurses. The use of
traveling nurses is also associated with tremendous and increased costs to health care
facilities. Some Vermont hospitals and health systems have been increasingly forced to
keep their ICU's, ER, Birthing Centers, and OR partially staffed by travelers.
• Anecdotally, more nurses are leaving the work force because of frustration with
practice, i.e., increased patient care responsibilities in face of reduction in force and
decreased length of stay, increased paperwork, negative physician interactions and
negative impact of HMO's.
C. Significant job dissatisfaction within the ranks of nursing is
threatening to further disintegrate the work force.
• Increased union activity as demonstrated by unionization in Copley Hospital,
Rutland Regional Medical Center, and Valley Regional Hospital (N.H.), as well as attempts
to unionize at Fletcher Allen Health Care, Cheshire Medical Center (N.H.), and
Androscoggin Valley Hospital (N.H.). Nationally, nine state nurses associations have
founded the SNA Labor Coalition whose purpose is to coordinate and strengthen labor
activities through organizing, researching, and responding to efforts by AFL-CIO
affiliated unions. Management Science Associates reports that hospital petitions for union
elections rose from 20 in 1989 to over 200 in 1998. Union victories in call health care
facilities rose to over 60% in 1998 according to National Relations Board.
• An American Society for Health Care Human Resources Administration study of 388
acute care hospitals, released February 22, 1999, illustrates our felt experience in
Vermont. This study found:
1. Concern for creating the environment for professional practice including
leadership models, educational support for ongoing professional development and career
opportunities.
2. Shortages of nurses in clinical specialty areas and nurse executives and managers,
contributed to the perception that clinical and management support for staff nurses is
lacking. This lack contributes to a difficult, dissatisfying environment for experienced
nurses, novices, patients, and physicians.
• Buerhaus, P. and Straiger, D. (1999) Health Affairs, 18, studied "average
hour wages" for registered nurses who worked in hospitals from 1983 to 1997. The
inflation adjusted hourly wages for nurses was $16.00/hr. in 1983, $19.28/hr. in 1990,
$19.45/hr. in 1994, and $18.61/hr. in 1997.
• Nurses report losing the ability to spend time at the bed side listening to and
meeting patients' emotional and spiritual needs. They feel forced to center on task
oriented and technological aspects of care. Consumers do not want a harried nurse that
they are "afraid to bother" with their questions or concerns as demonstrated by
patient satisfaction surveys such as Press Ganey and Picker.
• Core staffing patterns have been established in most practice settings. During
times of decreased census and acuity, nurses are financially hurt by a forced decrease in
hours and, thus, pay. During these times of increased census and acuity of patients,
inadequate help is available, causing increased over time and working short staffed, which
results in staff burn out.
• A faculty of 4 at Castleton now assumes the workload of a previous faculty of 9.
This reduction in force is directly related to decreased enrollments from an average total
of 100 to 50 students. Although diminished in numbers, professors and instructors must
continue to meet all regulations and requirements within Nursing Education Standards.
• Nursing Education departments in many hospitals have been significantly reduced
or eliminated at the same time that staffing levels on the units were reduced. This
significantly hampers facilities abilities to effectively mentor novice nurses and create
opportunities for the staff development of current nurses.
• Nurse managers frequently assume responsibility for two or more nursing units,
as well as, routinely filling in staff positions. OR Manager April 1999 reports, a
"manager wears many hats, often heading up a half dozen or more
departments,...they're juggling financial models, regulatory requirements, and a host of
technology changes. They maybe called on to organize a service line that pulls together a
variety of disciplines." This holds true in Vermont where, for example, a nurse
manger at a small rural hospital is responsible for OR, PACU, Ambulatory Care Center,
Pre-Op Testing, Minor Procedure, Endoscopy, Chemotherapy, Oncology Clinic, Central Sterile
Reprocessing, Pain Management Service, and ER patient populations. Similarly, in another
hospital, the Nurse Manager of the ER also acts as the only Nurse Educator for the entire
facility.
D. There is a true disconnect between schools of nursing and the field
of practice.
• Nursing schools have difficulty keeping abreast of advances in technology,
practice, and nursing protocols. This lag between nursing practice and education is
related to rapidly evolving nursing protocols and technology in the clinical practice
setting without an organized mechanism to communicate changes and advance the skills of
educators.
• Fluctuating census during students clinical experience hampers
both learning
opportunities and actual "hands on" practice. One faculty member is expected to
observe all direct patient care activities. However, the same faculty member is
responsible for up to 10 students in a clinical setting. This means students are sometimes
limited to observational experiences.
E. Nursing is not attracting the "best and brightest" of our youth into the
profession. Yet our field requires critical thinking skills to deal with the increased
complexity and acuity found in hospitals, home health care, and long term care, which
demands accurate assessments, timely interventions, and evaluation of outcomes of care.
This is demonstrated by:
• A reported increase in remediation activities with nursing
students.
• Stated outcomes of schools to prepare a minimally competent nurse, while stated
needs of practice are for highly competent, independent, and experienced practitioners to
be able to develop skills to be included in core staffing.
Solutions: A Strategic Plan
A state wide nursing retreat of key nursing leadership in March
'99 as well as the VAHHS Nursing Task Force has produced the following set of
recommendations designed to reverse the shortage and strengthen the ranks within nursing
for our future. We concur with American Organization of Nurse Executives.
President, Carol Bradley, RN who states, "hospital leaders and the public agree
that nurses are the backbone of the health care system. As such, ensuring that we have the
right type and supply of nurses matched to the demands within the health care system is of
critical concern. This is especially true as 'baby boomers' age and many nurses
retire."
Improvement efforts should be centered in both the arenas of education
and the field of practice. In summary, the following initiatives should be implemented:
I. Create a "Blue Ribbon Panel" representative of nursing and community
leaders to develop the strategies outlined below and take action to address the nursing
shortage in Vermont by the Year 2000. Short-term goals would include:
• Utilize current resources within VONL, State Board of Nursing,
State Nursing
Association, and specialty organizations to promote positive support for practicing
Vermont nurses.
• Utilize Human Resources associations within VAHHS to analyze
wage structures and recommend salary and benefits changes necessary to attract and retain
nurses.
• Provide this report to all CEO's and CFO's in institutions
across the continuum with nursing systems.
• Public Oversight Commission approval for increased dollars and
FTE within hospital budgets to implement necessary nursing initiatives.
II. Through marketing to the public at large and, specifically to high schools, attract
the "best and brightest" into the profession by advertising the personal and
professional rewards of a career in nursing. Some examples include:
• Opportunities to work with any age group in any setting across the entire
continuum of care.
• A chance to make a significant difference in the health and
comfort of Vermonters and their families.
• Job opportunities in occupational health, schools, hospitals and health systems,
home health and long term care in a time of high employment.
• A challenging career with diversity and opportunity for growth in practice and
education.
• Recognition as a valued member of a health care team.
• A flexible employment schedule around personal responsibilities, i.e., 12 hour
shifts and varying work hours.
• Advanced placement courses in high school leading to nursing
school.
• Hospital support for tuition reimbursement and loan repayment in
return for work
commitment.
• Career ladders for LNA, LPN, RN, Advanced Practice Registered
Nurse.
III. Promote a professional environment within facilities that
recognizes and values nurses, while providing enhanced job satisfaction. The components of
this model include:
• A nurse at the executive level within each organization
with authority, responsibility, and accountability for nursing that gives voice to
concerns within the nursing system.
• Decentralization of authority and
responsibility within the nursing structure.
• Opportunities for clinical advancement
within practice settings.
• Support for continued education and
professional development.
• Competitive salary and benefits models.
IV. Conduct research to study the variables in the practice of
nursing which link to improved clinical outcomes.
V. Create a formal nursing internship program that provides adequate
practical clinical experience for novice nurses to function at a competent level when they
enter the work force. This would force a marriage of schools of nursing and fields of
practice that could strengthen both institutions, while promoting the preparation of
nurses able to handle the currently complex and demanding field of health care.
V I. Expand clinical opportunities for students by increasing the use of clinical staff
as preceptors in specialty areas.
We would like to hear your
thoughts - Discuss
the Issues
VONL Nursing Shortage
Bibliography
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