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The nursing shortage had come to Valley Baptist Medical Center in Harlingen, Texas, and Patrick Ybarra, RN, nurse manager on the oncology and nephrology floor, noticed his RNs starting to act a little less like RNs: More and more of their time was taken up housekeeping, transporting patients and delivering food trays.

"Considering that recruitment is such a major issue here, I thought we could be using our RNs more efficiently," Ybarra said.

Recent studies agree: Support staff cutbacks and the nursing shortage are drawing RNs away from the specific work of nursing and toward ancillary jobs.

Kathie Vestal, Ph.D., RN, FAAN, vice president at Cap Gemini Ernst & Young, which provides health care consulting services, said nurses are too valuable to waste on the sorts of tasks they performed in hospitals 50 years ago.

"We need to get RNs to do what only RNs can do," Vestal said. "Institutional attempts to get them to do more broad tasks have not worked. The average nurse in this country is in her mid-40s.

"We need to find a solution to the problem of a person approaching her 50s, having to perform a physically and mentally demanding job, day in and day out, with minimal to no support staff."

Linda Aiken, Ph.D., RN, FAAN, professor of nursing and sociology at the University of Pennsylvania, said, "In the United States, nurses have the most education, but too often they're doing the non-nursing tasks. It's simply a major misuse of a scarce resource."

Aiken co-authored the study "Nurses' Reports on Hospital Care in Five Countries" (published in the May/June 2001 issue of Health Affairs) to assess how staff mismanagement, cutbacks and other factors have overburdened nurses, exacerbated burnout rates, fostered job dissatisfaction and compromised patient care.

RNs in other countries surveyed (Germany, England, Canada and Scotland) had similar complaints about being asked to perform non-nursing functions.

"All these countries have a nursing shortage. The point is that nurses are a scarce resource. They should be primarily dedicated to the provision of nursing functions," Aiken said.

Hospital cutbacks in support personnel such as patient transporters, food delivery workers and CNAs can lead nurse managers to use RNs ineffectively.

The problem may stem from the health care industry's patient-focused initiatives that were launched in the '80s. With time, as reimbursements dropped off and patient acuity increased, the focus veered away from patients and toward cutting costs, Aiken said.

Different strokes
Some hospital RNs aggravated the problem by negotiating contracts that stipulated they would be the last to go, said Joanne Spetz, Ph.D., an economics research fellow at the Center for the Health Professions at the University of California, San Francisco. California nurse-patient staffing ratios, which the California Department of Health Services will put into effect Jan. 1, only will worsen the problem, she added.

She recommends letting institutions figure out the best alternatives for themselves.

"Different hospitals will have different solutions to the problem; there's no one-size-fits-all approach," Spetz said.

"I hear from nurses who complain either way: some who don't want to perform these non-nursing functions, and others who say they don't want to delegate chores such as changing pans to nonlicensed staff because that takes them away from their patients. It keeps them from assessing and so forth."

At Valley Baptist, Ybarra worked with the administration to improve the training and use of CNAs to fill the gaps. About two years later, a support staff of 199 helps the 502 RNs concentrate on nursing their patients rather than serving them lunch, Ybarra said.

"The CNAs free up the nurses' time. I don't agree that this is taking the RNs away from their patients for too long. This allows them more time to assess a patient and talk to him or her face to face, instead of doing three other things and saying something over their shoulder as they walk out the door, hurrying to their next patient."

But CNAs are no panacea, some say.

In nursing homes, the nursing shortage and other factors make working conditions more difficult than in hospitals, said Charlene Harrington, Ph.D., RN, a professor of sociology in the UCSF Department of Social and Behavioral Sciences.

In such institutions, the national average ratio is 34 patients per RN or LVN, who usually earn 15 percent less than hospital nurses.

For the majority of patient care, nurses usually must rely on CNAs who are paid an average of about $7 an hour, with a turnover rate of 93 percent.

"RNs hardly have time to even give medication, let alone perform other functions," Harrington said. "Besides, RNs are not trained to supervise these people. They're constantly having to train and orient new CNAs, taking more time away from their already more than full schedules."

Nurses with patients
To begin to relieve the problem, Aiken argues for a stricter demarcation between RNs and other clinicians, aides and housekeeping staff.

"The people with the least education should not be with the patient. Among other things, studies have shown that needlestick rates are higher the more time the unlicensed worker spends with patients. It needs to be nurses performing these nursing tasks and support personnel providing support."

In the end, only fresh approaches will solve the old problem of overburdened nurses, she said.

"We need to explore a technological solution: advanced medical equipment, communications systems, charting software, simplified data entry, robotics for patient transfer.

"Some say this will be expensive, but today every time a nurse leaves, a hospital has to spend $145,000 to recruit, retrain and retain a new one."

A culture of greater respect for the nursing profession wouldn't hurt either, Aiken said.

She was bemused to discover that German RN respondents to the five-nation survey she co-authored had deleted one question: whether they performed housekeeping duties on the job. This implies that in Germany, nurses don't have to do housekeeping, Aiken said.

"I think they were angry at having been asked whether they made beds," Aiken said.

The survey also showed that German nurses reported a job satisfaction rate of 82 percent.