Photos Courtesy of Clarian Health	(Interactive Map) Nursing Shortage Legislation around the country Nursing Shortage Library New legilslation a positive step, but pitfalls remain Graphics and Charts
Flight Nurse Lori Swoboda explains LifeLine services to a group of Career Camp students at Clarian Health in Indianapolis.

It's been four years since Jeremy Jackman, RN, became a nurse. But he hasn't forgotten his first day on the job.

"They gave us a bunch of patients," he said. "It was kind of trial by fire."

When his employer, St. Mark's Hospital in Salt Lake City, started a mentoring program for new nurses, Jackman offered to help.

"I volunteered so I could make it easier for other people," he said. "A lot of times, people come in, they're thrown into it, it's high stress, they don't know what they're doing exactly, and that doesn't create a good working environment. The stress finally gets to them and they quit."

St. Mark's is one of a number of organizations and individuals, including health care employers, nursing schools and legislators looking for solutions to the nation's nursing shortage. At St. Mark's, experienced nurses like Jackman who agree to mentor a new hire receive bonuses for every six months that the new hire stays. The nurses are matched for skills and interests, and both have a lighter workload until the less experienced nurse is up to speed.

Last year, 24 percent of the nurses who left the hospital did so after only three months or less. But no new hires have quit since the program began in January.

The mentoring program at St. Mark's is working, but the payoff for other programs may not happen so quickly. Experts caution that it could be years before it's clear which ideas and innovations should spread and which should be sent to the junk heap.

But one thing is certain, they say: To solve the shortage problem, policy changes and programs not only must increase the supply of nurses, they must reduce the steady stream of nurses leaving hospitals to a trickle by making nurses a valued and respected part of the health care system.

Negative effects

Decades ago, nursing was one of the few career options for women. But as more highly paid and prestigious jobs opened to them, fewer and fewer women chose nursing.

Through the years, nursing hasn't attracted men and minorities. Men remain a sliver of the nursing population, while the number of minorities in nursing is just a fraction of their percentage of the population. The growth of managed care in the 1990s contributed to the problem as well. As companies worried about declining profits, they cut their nursing staffs.

The declining number of people entering the profession and job cuts contributed >> not only to the present shortage, but created stressful working conditions for the nurses who stayed.

In a NURSEWEEK/AONE study, seven out of 10 hospital nurses polled said they had witnessed a negative effect on patient care quality because of the shortage. At least two out of three working RNs said they'd seen an increase in the turnover of experienced nurses, more patients per nurse and an increase in overtime or double time for nurses in the past year, according to the survey.

Those problems are expected to escalate in the next 20 years. In 2000, the number of registered nurses in the country was 6 percent below the demand, according to a new report from the National Center for Health Workforce Information and Analysis by the U.S. Health Resources and Services Administration.

That number will leap to 29 percent by 2020, according to the report.

Recruitment drive

Many of the new initiatives geared toward curbing the shortage are designed to ramp up the number of people entering the profession. Many states have passed bills to increase student enrollment in nursing schools and to add school capacity.

At the federal level, Congress recently passed the Nurse Reinvestment Act that President Bush signed into law. The act is a multipart piece of legislation designed to attract and retain nurses. Nursing advocates hail its quick passage as a victory, but its lasting effect remains to be seen. No money has yet been attached to the act, and advocates say getting as much as the law needs will be an uphill battle.

Meanwhile, health care employers also have started to look at ways to increase the nurse supply. Some, like Clarian Health in Indianapolis, are doing that by reaching out to minorities.

For the past four summers, the hospital has hosted a career camp for local minority at-risk youth. The camp, in partnership with Goodwill Industries, puts kids in the hospital during the day for a three-week period. They shadow the health professional of their choice, learn more about different health careers and are mentored by hospital staff.

The experience may be brief, but it leaves a lasting impression, said Sherry Makely, Ph.D., manager of educational services for Clarian. "We did a quick telephone sampling [after the camp] and found the majority of them are continuing on with their health career plans," she said.

Several have come back to Clarian, Makely said. "We hire a few of the best ones to be interns, or we hire them to work part time in an after-school job. They get to know us, and they realize that we have a support system here," she said.

Clarian would like to reach more minority youth through a partnership with the Indiana Minority Health Coalition. The coalition has applied for a grant to help minority high school students learn about careers as nurses, pharmacists and other health care professions affected by the shortage. The partnership would set up a telementoring program partnering children around the state with health professionals from matching racial or ethnic backgrounds and fund career days in high schools.

Other hospitals have come up with innovative ways to increase the nursing pool from within. At Holy Family Hospital in Methuen, Mass., nursing assistants are paid to go to school to become nurses.

"Some of our students have families that they couldn't support if they didn't have that additional pay," said Jacqui Collins, MSN, RN, the hospital's clinical educator. "It just gives them an edge when they get to school."

The program began in February 2001. Nursing assistants regularly work 32 hours per week at Holy Family. But students get a break. Those taking between four and seven hours of classes each week receive eight hours paid credit and work just 24 hours. Students who are in class seven to 12 hours per week work half time and earn 16 paid hours for being in class.

Although the nurses haven't yet graduated, Collins said she expects the program to be a success.

"We're comfortable with them, we know that they have great work ethics and that they're good [assistants], and that will translate into good nurses," she said.

Educational options

Attracting more students to nursing is one strategy. Hospitals also are trying to give existing nurses more educational options. A common complaint among nurses is that it's difficult to advance professionally. Some employers are tackling this dilemma by offering employees a little scholastic assistance.

Catholic Healthcare West, a nonprofit organization with 42 hospitals in Arizona, California and Nevada, is one example. The organization has partnered with Holy Names College in Oakland, Calif., in a distance-education program to help nurses with associate degrees and nurses from other countries earn baccalaureate degrees conveniently.

Classes taught by college faculty are beamed to eight Catholic Healthcare West hospitals from a studio at the college. The nurses can take classes without having to search for a program or trying to squeeze classes into their work schedules.

The program now has about 60 distance-learning students, but Fay Bower, DNSc, FAAN, chair of Holy Names College Department of Nursing, hopes to double the number of students next year.

"I think it's opened the nurses' eyes to what's possible at the institution they're in, beyond what they're doing, so they have new skills, new ideas and knowledge," Bower said.

Other hospitals are trying to retain nurses by improving inhouse technology in the hopes that it will enhance the work environment.

Children's Hospital and Health Center in San Diego has initiated a new system on desktop and laptop computers in several departments to help eliminate frustrating paperwork. The program carries forward old parts of charts so nurses don't have to rewrite the same information.

Finding specific information is easier with the electronic charts because nurses can search through different windows on the screen rather than wade through papers and sloppy handwriting. Several people can view the chart at once, too.

But the best part of the program is the "help" key. Instead of explaining how to use the system, the key provides the kind of assisstance that a busy nurse needs, including the range of normal temperatures for children of different ages and explanations on performing unfamiliar procedures.

Staff and administrators say the new technology-particularly the help key-has proved popular with nurses.

"New staff coming in from another aspect of nursing, especially the adult world, use it tremendously," said Seja Plavisic, RN. "I still see those of us who are seasoned for decades using it. I look things up to see whether I'm on the cusp of care with certain kids or not," she said.

"I don't know if it's saving time," said Linda Travis Macomber, MBA, RN, clinical informatics analyst at the hospital. "But it's saving lives and nurse frustration, and that's a huge issue in nurse retention," she said.

New perks

While some employers are trying to make nurses want to stay, others are encouraging nurses to grow roots.

Help in buying a home is a new benefit offered by some hospitals. Fannie Mae, a housing financial services provider, is working with more than 50 health care employers across the country. While some employers choose to offer only counseling, the most typical perk offered to nurses is a no-interest loan forgiven at 20 percent per year in the course of five years, said Beth Marcus, director of Fannie Mae's National Community Lending Center.

The loan works because "from the employer's perspective, your goal is to get them to stay. From the employee's perspective, they get the money up front," she said.

How well nurses like the new benefit is difficult to tell because Fannie Mae didn't start to track its use in hospitals until a year or two ago, Marcus said. But within Fannie Mae itself, where housing assistance has long been a part of the benefits package, turnover in nine years was 25 percent lower among employees who used the housing benefit compared to those who didn't, Marcus said.

Nursing experts say these programs generally are good steps toward a solution.

The St. Mark's and Holy Names programs are particularly good ideas, said Joanne Spetz, an adjunct fellow at the Public Policy Institute of California at the University of California, San Francisco.

The mentoring program is "a good start to really try to give new nurses a chance to ease into it and give them more structured guidance to help them learn the ropes," she said.

But the program does have a pitfall, Spetz said. If a new hire quits for reasons that have nothing to do with the mentor, the mentor still is punished, she said.

The nursing assistants who complete the Holy Names distance-learning program are a better bet than average nursing school graduates, Spetz said. "People who work in a health care environment before they go into nursing have a more realistic view about what nursing is, and are more likely to stay," she said.

But Spetz and other experts say employers are just starting to tackle the biggest issue in solving the nursing shortage.

If employers want nurses to stay, they must respect nurses' opinions and concerns and help nurses feel they are doing the best they can for patients, said Rose Gonzalez, head of legislative affairs for the American Nurses Association.

"We believe that when you provide nurses with a say in patient care and make them part of the decision-making process, care improves and the nurses are more likely to stay," she said.

Gonzalez said the ANA strongly supports the Magnet hospital program by the American Nurses Credentialing Center, a subsidiary of the ANA. The program awards special status to hospitals that show best practices and excellence in nursing and caring for patients.

To earn Magnet status, a hospital must follow standards for improving patient care, promote quality professional nursing practice, pay attention to the cultural and ethnic diversity of patients and staff, and have strong leadership and support for nurses from nursing executives. More than 50 health care centers have received Magnet status since the program started in 1993, and studies on the hospitals have shown that nurses at Magnet hospitals are less likely to suffer from job burnout than at non-Magnet facilities.

The Magnet program "does work to change the culture of the institution to value and respect nurses," Gonzalez said. "That's why we are very supportive of that program. We believe it is the workplace that's driving nurses away."

Changing the culture

A system that consistently gives nurses a voice in patient care and makes them a respected part of the health care workforce may seem a far-off dream. But getting there isn't as difficult as it seems.

Baptist Health Care, with five hospitals in or near Pensacola, Fla., is one example of how an employer can dramatically change for the better for nurses and patients.

In 1996, turnover among nurses at Baptist Hospital was 30 percent annually. Before 1996, the hospital also was well below average in patient satisfaction.

The administration decided to make a change by placing more focus on patients and on employees. Nurses now get more of a say in the day-to-day running of the hospital. They are encouraged to make suggestions on improving patient care and cutting costs. Staff members interview prospective new hires, and a majority of them must agree on a new person before he or she is hired.

Employees continue to earn an annual merit raise averaging 3.5 percent, but after 1996, management added an annual market adjustment to keep wages at the median level for the area. Management also decided to promote an open culture by sharing the company's financial information, encouraging employees to talk about any problems.

Nurses can do small things to help patients independently. They can bend visiting hours on special occasions, get family members meal tickets if they've arrived late and are hungry, or buy patients or family members small gifts, according to Brian Jones, RN, who works in the hospital's intensive care unit.

"The bosses kind of let you do what needs to be done, and they back you with whatever they need," he said. "You can have a policy and a procedure all day long, but there's always times you need to do things like this to do what's right for the patient."

Changes like these may seem small, but they've made a big difference. This year, Baptist Health Care was one of two hospital systems on Fortune Magazine's list of the top 100 companies to work for.

Baptist Hospital is in the 99th percentile in patient satisfaction, according to Press Ganey Associates. Nursing turnover at the hospital is down to 12 percent-an 18 percent drop from the hospital's 1996 rate.

Part of the present turnover may be due to a price war among hospitals in the area. Like most nurses, money is a consideration for Jones. But he has no intention of leaving Baptist Hospital anytime soon.

"Once you start working where I work, there are a lot of other things that are more important than money," he said.

Contact Jessica M. Scully at Jessicam_scully@yahoo.com.