It's 6:30 p.m., half an hour shy of the end of a 12-hour ICU shift at Mercy Medical Center in Roseburg, Ore. Three nurses pore over charts, scan reports, click a keyboard and scurry across the room to empty a urine bag, adjust a hose, raise a bedside rail.

Chronic illness dominates today's caseload: lung disease, acute post-cardiac arrest, bleeding ulcers. The seven-bed unit in a 126-bed hospital serves a town of about 20,000. "In a small, rural hospital like this, the ICU nurses have to be very generalist," said Rebecca Lethlean, RN. "We take care of them all."

Yesterday buzzed with excitement-a coding patient, an intubation, a transfer to an out-of-town hospital. Today it's quiet, they say. But slow and quiet are ominous words.

"You can't say the 'S' word here," jokes Toni Stevens, RN.

"Nurses are very superstitious," Lethlean adds.

When it's busy, they shuffle patients around. Healthier patients move out; new ones arrive. "We juggle beds all the time," Stevens said.

She makes coffee for the night crew as, nurse by nurse, the day shift files into the post-anesthesia care unit, giving status reports in a vacant room.

At 7:47 p.m., the day nurses pack up and exit through wide, electronic doors into the waiting room, 13 hours after their arrival. "I would say that we're late getting out probably 95 percent of the time," Lethlean said. "My daughter's usually in day care 13½ hours."

Such is life in ICU nursing-and she loves it.

Their jobs make national headlines as health care faces a crisis. An American Hospital Association report released in June notes 168,000 unfilled hospital positions nationwide; 126,000 are for nurses. Nursing demand outpaces supply.

A recent broadcast of "Nurses: Critical Care," on the Discovery Health Channel predicted critical care nursing will be hardest hit. Many in the field agree.

Yet nursing woes are startlingly complex, with causes and effects as varied as patients and nurses in an ICU. Opinions vary, too.

"I believe the greatest shortage is in critical care," said Kathy Sanford, DBA, RN, vice president of nursing and administrator of Harrison Memorial Hospital in Bremerton, Wash. "This appears to be everywhere."

"It is more difficult to recruit nurses for med/surg than critical care," said Pamela Jordan, MS, RN, manager of nurse recruiting at Parkland Health & Hospital System in Dallas.

"I'm seeing that the shortage is just pretty much universal, across the board," said Linda Daum, MBA, RN, chief nurse executive at McAllen Medical Center in Texas.

"I think it's important to question whether there really is a nursing shortage," said Liz Jacobs, RN, communications department, California Nurses Association.

"We believe there is a critical shortage [of] experienced and competent nurses right now as we speak," said Justine Medina, MS, RN, practice director, American Association of Critical-Care Nurses.

All emphatic, all different.

"There are so many factors that fit into this," Daum said. "It depends on who you're talking to and what the situation is in their county and their hospital."

Most nurses and administrators agree on several phenomena-an aging nurse population, an aging patient population with greater medical needs, not enough nursing students, poor working conditions, wider career options for women and wider job options for nurses.

But specialty nursing has its own characteristics that make it difficult to hire and retain nurses.

Critical care units generally require one nurse for every one or two patients. On general floors, nurses sometimes handle six to 10 patients. Specialty areas require more experience. Training is expensive. The job attracts nurses who like risk and a fast pace; those nurses tend to be younger. Younger nurses gravitate toward bigger cities and high-tech hospitals. Nurses work 12-hour shifts and overtime to fill the gaps. Such combined factors further stress nurses-and dissatisfied nurses often leave.

"The nurses are out there," CNA's Jacobs said. However, she said they don't want to work in hospital settings. Jacobs said that 33 percent of California's nurses work part time, about 40 percent work in nondirect care and 17 percent aren't practicing nursing. "If you put all that together, there's a pool of many nurses to draw from."

But luring and keeping them is another story-particularly in specialty areas.

"Typically, the specialty areas are higher stress, and this can cause burnout in many," said Karen DeLavan, senior recruiting consultant for Texas Health Resources. "Specialty nurses tend to be Type A personalities-very driven, dedicated and hardworking. It is tough to do this for too long, and hard to do with a family. Our nurses are aging and getting tired of 12-hour shifts, typical for specialty areas; tired of lifting/moving patients; tired of the extra shifts; and tired of all the stress."

Nurses are leaving hospitals for agencies that pay more. "The number of new graduates is decreasing, and this means fewer who can go into internship programs to train for the specialty areas," DeLavan said. "The new grads that we do have coming into our system tend to be more interested in going into the specialty areas rather than the medical/surgical and general areas. While this is good for the specialties, we are seeing this hurt our general areas."

Germaine Williams, RN, nurse clinician 3 at Johns Hopkins Hospital, who was featured in "Nurses: Critical Care," said training and experience are key to critical care. "The orientation is longer because there's a lot more technical responsibility. If an ICU nurse has three or four critical patients, you're getting into a dangerous situation."

That's not all. "The EDs are constantly backed up," said Art Lathrop, emergency medical services director for Contra Costa County, Calif. "I think we can certainly say hospital overcrowding and ED diversions have reached a crisis in California."

Sanford, of Harrison Memorial, said patients, many of them uninsured, increasingly visit the ED for primary care. When critical care beds and nurses aren't available, those patients stay in the ED. Hospitals then divert ambulances elsewhere. "But sometimes everyone in the area goes on diversion, so the EMS just goes to the closest hospital whether they have room or nurses or not."

Such backups are dangerous, said Virginia Hastings, director of emergency medical services for Los Angeles County. "I'm sure that we've had patients die that we don't know about," she said. "We know that patients are not being admitted for hours and hours and hours. I know some of them are held up to 76 hours."

Hospital overcrowding hasn't always been an EMS issue, Lathrop said. "That was just something outside the realm of what we deal with. Today, it's just totally different."

He said managed care increases patient acuity. Five years ago, not all ICU patients were as critical as they are now.

"The eight patients who are there need to be there," he said. "They can't really do anything. We've lost the flexibility in our system that we used to have." Hospitals staff for an anticipated capacity. "When you happen to go 20 percent over the expected capacity, which is not unusual, you can't meet it," Lathrop said. "The ways we did things 10 years ago were undoubtedly less efficient but they definitely provided more flexibility."

Furthermore, some question 12-hour shifts, popular among specialty nurses. "Probably 75 percent of nurses who work 12-hour shifts would disagree with me," said Tamara Wardell, MSN, RN, a Ph.D. student at Duquesne University in Pittsburgh. "I'm tired after eight hours. After 12 hours, I'm exhausted. I think it contributes to the problem we're having nationwide with errors."

Solutions, like the problems themselves, are individual.

"A nurse is not a nurse is not a nurse," said Fran Martinez, MS, RN, vice president of nursing services for Roseburg's Mercy Medical Center. Younger nurses like vacation packages and 12-hour shifts, she said; older nurses prefer retirement benefits. "It is not a 'one solution fits all.' "

Daum of McAllen Medical Center offers retention bonuses after working one year and signing for at least one more. If nurses leave early, they must repay the bonus. "I don't want my money back," she said.

But specialty pay for specialty areas doesn't work, she said. Her hospital once offered nurses 10 percent more to work in ICU. "They hated their job," she said. "If I'm working where I don't want to work ... it's not healthy."

Daum also trains inexperienced nurses. "I put people through an internship, and I put new grads into my specialty areas." She must cover for the inexperience, she said, but they gain experience with time.

It's a solution some administrators shun. Training is costly. "Remember, these nurses are earning a salary while they are being trained," Jordan said. "So you are talking a considerable number of paid nonproductive hours."

Mary Nash, Ph.D., chief operating officer/chief nursing officer at University of Alabama Hospital, said she hires recent nurse graduates for the ICU.

"There are some hospitals that won't do that." The nurses go through a 12-week orientation. They are tested and taught individually tailored programs. "This is a very ICU-intensive hospital," Nash said. "We cannot afford to not have our ICUs staffed. We have to be creative."

Several hospitals have taken similar routes. The Association of periOperative Registered Nurses offers an education package that hospitals can use to "grow their own" perioperative nurses. California State University, Los Angeles, worked with local hospitals last summer to create a 10-week specialty nursing course. Hospitals provided people from their own units to teach the clinical aspects.

San Francisco General Hospital has offered special ED and critical care programs. "Now we have zero percent vacancy rate in ICU," said Mary Jo Webb, director of emergency nursing at General. "We've just been very lucky. Next month, we could have a severe shortage again."

Legislation is another tack. The federal Nurse Reinvestment Act would put money into scholarships and recruitment programs; that bill now sits in committee.

In California, a state budget crunch has stymied several legislative efforts.

"Nothing's going anywhere," said Jim Lott, MBA, executive vice president of the Healthcare Association of Southern California. So he's looking elsewhere.

The state has about $500 million in federal grant money for high-tech. "They were mainly thinking about the computer industry, but it also was opened up to include nursing." His group would like to earmark about $40 million for nurse training.

California passed a bill in 1999 that will take effect in January, which mandates nurse-to-patient ratios. This summer, Oregon also passed a bill that limits mandatory overtime, addresses staffing needs and protects whistle-blowers who report unsafe and illegal practices.

"Hospitals must base their staffing on the needs of the patients," said Susan King, MS, RN, administrator for the Oregon Nurses Association. "They will redirect the hospital's attention to the primary reason it exists, and that is the care of its patients."

Back at Mercy Medical Center, that attention is fixed on six ICU patients. Perhaps focus is an industry problem, but not a nurse's problem. For all the challenges that face the health care system, most agree that nursing is a passion. Particularly in critical care.

For Lethlean, it's a calling more than a job. She originally wanted to be an ob/gyn nurse, but now she's attached to ICU.

She empties a urine bag, tosses gloves into a bin, washes her hands, paces the floor. A lot of handwashing, a lot of lotion, sometimes 60 times a day. Back and forth, back and forth, she breathes a little sigh.

The ICU is Lethlean's niche. As many nurses point out, it takes a true fit.

"I'm right at home here," she said.

 

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The word on the OR floor

Despite talk of a nationwide nursing shortage, a recent survey has shocked nurses and administrators with results that show almost no shortage of OR nurses for the second consecutive year.

The survey of 400 randomly selected OR directors found hospitals have, on average, 1.4 OR nurse positions unfilled and 51 percent have no unfilled positions. The Gallup Organization conducted the survey for Surgical Information Systems, a private Atlanta-based company that provides medical software and information.

Those findings contradict the word on the floor.

"The statistics may show one thing, but the real-world experience is something different entirely," said Janet Paulson, MSS, public relations manager for the Association of periOperative Registered Nurses. AORN members tell her they have a shortage, she said. "They have a hard time keeping their positions filled."

"OR is our big problem right now," said Mary Jo Webb, director of emergency nursing at San Francisco General Hospital. She is surprised to learn of the survey results. "Really? That is really interesting. I know we're down four or five positions in the OR." She said hers is not the only Bay Area hospital with an OR shortage.

Drew Cobb, MAS, Surgical Information System's vice president of systems development, said he gets that reaction all the time. "They don't believe it," he said. "OR directors will tell you that yes, it's an issue."

They perceive a shortage, but "they can't produce the numbers to back it up."

He says many nurses react emotionally to the survey results. Other surveys indicate shortages in other units, he says, but "some of the nurses will take one survey and think it applies to them."

Cobb is an AORN member. "I am an OR administrator. I've run OR rooms."

He attributes the results to two issues. "In the past, a nurse went to work in the hospital and stayed there forever. Nurses now tend to move around more." He said he asks OR directors whether they have empty positions and they say no. People leave, but the positions are filled again.

The other issue is work environment. "Quality of life for the operating room nurse has become quite bad." Poor management, inconsistent case volumes, long hours with few breaks-such factors combine to dissatisfy OR nurses. If conditions improve, Cobb said, many OR managers think there will be no shortage. "Numerically there isn't really a shortage right now," he said.

But the survey also indicates OR directors worry about the future, particularly with an aging workforce. According to the survey, 37 percent of OR nurses are between ages 41 and 50; 14 percent are older than 50.

"We expect to lose 20 percent of our membership in the next five years because of retirement alone," said Candace Romig, AORN director of government affairs.

The survey also reports that nurses spend too much time away from patients. "Almost 40 percent of their time is not doing patient care," Cobb said.

Cathe Clapp, MN, RN, vice president for nursing at Swedish Medical Center's Ballard Campus in Washington, said hospitals must determine whether other employees can tackle some of the nurse's workload. Can a physician assistant do it? Can new equipment do the work? "We should have no nurses doing anything anyone else can do."

The survey has been enlightening, Cobb said. "This is the second year in a row. It leads to a lot of interesting discussions," he said. "If there is indeed a shortage coming, I would put the emphasis not on the nurses, but [on] the hospitals and support systems."

~Karen J. Coates