Winter 2001-'02 Article from "Arizona Economic Trends" Newsletter
Even as more and more Arizona firms announce large layoffs, driving Arizona's unemployment rate up, large numbers of vacancies exist throughout the state for registered nurses. The Arizona Hospital and Healthcare Association (AzHHA) reports a statewide average registered nurse vacancy rate of 16 percent.1
A vacancy rate of that magnitude implies that there are more than 5,000 registered nurse (RN) jobs around the state going wanting for qualified candidates, on average, given the Department of Economic Security, Research Administration (DES, RA) estimate of 32,070 registered nurse jobs statewide in 1999.2 There are corroborating statistics from the Healthcare Institute of the AzHHA, which has determined that in 2000 there were 33,135 active Arizona RN licenses and that 90 percent of the RNs were in the workforce, a larger share than the national average (82.7%).3
Arizona is not unique. A nurse shortage exists nationwide with some areas worse off than others, and Arizona as bad off as any. The national average nurse vacancy rate is 11 percent, according to AzHHA, and there are 2,115,815 active nurse licenses with 1,749,779 nurses in the workforce.4
Reasons for Shortages
Assorted studies have identified multiple reasons for the short supply of registered nurses in Arizona and nationally:
An AzHHA study cites Arizona's fast population growth (40 percent increase between 1990 and 2000), while Arizona's educational systems are graduating only slightly more RNs now than 10 years ago.5
Job dissatisfaction and the aging of the nurse workforce are other reasons, according to a General Accounting Office (GAO) report in July to the U.S. House of Representatives' Ways and Means Committee Subcommittee on Health.6
Fewer young women are choosing a nursing career, because they now have more alternatives from which to choose.7
Managed-care health insurers have reduced reimbursement rates to acute-care facilities, requiring lower operating budgets, which have constrained salaries.8
Immigration laws constrain importing nurses from countries, such as Spain and the Philippines, with surplus supply.9
Job dissatisfaction--which results from a variety of circumstances in the nurse environment--was cited often as the most egregious factor leading to short supply. Short staffing--in part resulting from the shortage and in part from reassignment of duties by managed-care companies--requires the remaining nurses to provide care to more patients. Nurses who believe they can't give the quality of care they have been trained to provide feel frustrated. Short staffing also leads to mandatory overtime that can make it difficult to juggle the needs of work and family. It can also be just plain exhausting. Moreover, in some institutions, physicians' poor treatment of nurses is another circumstance adding to dissatisfaction.10
Constrained salaries, regardless of cause, are another source of job dissatisfaction for RNs. Despite all the other reasons for dissatisfaction, salary levels remain an important motivator for attracting young people into nursing careers and keeping experienced staff on the job.
According to the GAO report to Congress, RN earnings have just kept pace with the rate of inflation from 1989 to 2000.11 National median pay for registered nurses was $40,700 annually in 1998, a level only slightly above the Arizona median of $40,300. Putting it another way, Arizona's average RN pay was slightly below the national average, ranking 20th among all states, the District of Columbia, and Puerto Rico.12 Registered nurse median pay in Arizona ranged from $48,838 in Maricopa County to $34,736 in Graham County in 2000, according to DES, RA's latest published survey.13
Another factor contributing to the nurse shortage is the degree of difficulty imposed on employers who want to import trained nurses from other countries. While the U.S. has been importing nurses from other countries for many years now, the process has waxed and waned in its degree of difficulty. In addition, each foreign country is allowed a specific quota, and the numbers permitted have risen and fallen as Congress has adjusted quotas up and down.
Currently, nurses have favored status in the immigration and visa processes. The North American Free Trade Agreement (NAFTA) has permitted importing nurses from Canada without limit, according to Russel Ahr, a Phoenix-area spokesman for the U.S. Immigration and Naturalization Service (INS). More generally, RN's are listed on "Schedule A" for category H visas, which exempts sponsoring employers from having to file a "Labor Condition Application." Many employers perceive the Labor Condition Application as an onerous process, because it requires that U.S. employers' jobs be advertised in this country for six months at the local labor market's "prevailing wage" before the employer's petition will be honored.14
Once obtained, the category H visa grants permission to work in the U.S. for three years, and a three-year extension is permitted after that if the employer applies for it. However, during the permitted period, the foreign nurse may apply for a "green card" granting permanent permission to work in the U.S. Once a green card is obtained, the employer may lose that nurse to another employer and thus lose its sponsorship investment, since the nurse no longer requires a sponsor.15
The sum of these and other factors causes or exacerbates the shortage of nurses, and the shortage leads to consequences that are threatening the well-being of patients.
Consequences of Shortage
Nowhere
is the shortage of nurses felt more painfully than in the emergency rooms and trauma centers of the state. More and more people are entering the health-care system through emergency rooms, because they have no health insurance. And emergency rooms can't turn patients away once they are present.
The federal Emergency Medical Treatment and Active Labor Act (EMTALA) mandates that hospital emergency rooms treat all comers--at least to the point of stabilizing their condition--regardless of their ability to pay.16 Yet emergency room staffing is strained to the limit trying to deal with the excess number of patients. It is often the case that an emergency room patient arriving in the afternoon isn't treated until the wee hours of the morning. Triage nurses examine patients as soon as they can after the patient's arrival (as required by EMTALA), but if the patient's injury or illness is not judged to be life-threatening, any care they may need may be delayed for hours. Moreover, patients who are transported by ambulances may be diverted from going to the nearest hospital, and instead sent to hospitals further away that are not as crowded.
The problem is, most emergency rooms are crowded, and it is not unusual to be diverted to yet a third hospital or be required to wait in a line of ambulances for a turn to get into an ER. In fact, there were eight occasions between January and April 2001 when all of Phoenix's 29 emergency rooms were simultaneously closed and thus diverting all ambulances.17
Emergency room crowding is caused by constrained outflow, in addition to over-abundant inflow. Hospitals often make ER beds unavailable to new patients because there aren't enough beds in the rest of the hospital for ER patients. The lack of beds is often not a matter of insufficient hospital rooms, but rather insufficient numbers of nurses to provide service to the hospital rooms.18 A bed is not a "hospital bed" unless there is a nurse to care for the patient that's in it. Recently, Tucson Medical Center had sufficient nurses to staff only 301 of its 609 beds; University Medical Center could staff only 249 of 365 beds; and Tucson's St. Joseph's Hospital had enough nurses for but 181 of its 301 beds.19
Some Proposed Remedies
At a ceremony honoring Tucson Medical Center nurses last May, Arizona Gov. Jane Dee Hull announced she was putting together a task force to study the nurse shortage and propose solutions. Hull also praised Tucson Electric Power Co. for promising to donate over $150,000 over three years for nursing scholarships at Pima Community College.20
At the federal level, Department of Health and Human Services (HHS) Secretary Tommy G. Thompson announced federal grants and contracts totaling more than $27.4 million to increase the number of qualified nurses nationwide. HHS' Human Resources and Services Administration will award 94 grants totaling more than $20.1 million to 82 colleges, universities, and other organizations to increase the number of nurses with bachelor's and advanced degrees. The money is also intended to help diversify the nurse workforce and prepare more nurses to serve in public health leadership roles. Another $7.3 million will help repay educational loans of clinical care nurses who agree to work for two years in designated public or nonprofit health facilities facing a critical shortage of nurses.21 Arizona State University will receive $244,147 in Advanced Education Nursing Grants and $343,652 in Basic Nurse Education and Practice Grants from HRSA.22
Another federal solution was proposed in the "Nurse Reinvestment Act," a bill introduced in the spring 2001 session of Congress by Senators John Kerry (D, Mass.) and Jim Jeffords (I, Vermont). The bill would create a National Nursing Service Corps, which would require serving two years in a health facility with a critical shortage of nurses in exchange for nursing school scholarships. It would also encourage national and local media campaigns to promote the field of nursing as a career.
A companion bill introduced in the House of Representatives had the support of several national nurse organizations, such as the American Organization of Nurse Executives and the American Health Care Association.23, 24 In late December, both the House of Representatives and the Senate passed their versions of the Nurse Reinvestment Act, with the differences to be hashed out in a conference committee in 2002.
One private-sector approach to filling gaps in the nursing ranks was advanced by UCI Medical Center, a California health-care facility. It has offered a $3,000 signing bonus for nurses joining one of its short-staffed specialty units. It also offered a $500 bonus to nurses who recruited new co-workers. UCI is only one of about 30 California hospitals that have instituted signing bonuses. It was reported that the Kaiser Permanente Medical Center in Roseville was offering one of the highest amounts--$75,000.25
Need a Career? Be a Nurse!
If you want a career that almost guarantees that there will be a job at the end of your training, consider becoming a registered nurse. Despite the shortfall of nurses, the deficiency will be worse as Baby Boomers age and retire. With an aging population, the demand on the U.S. healthcare system will grow ever larger.
Notes:
1. "Nurse Shortage Worse in Arizona," Inside Tucson Business, Kyle, Schliesman, Internet Edition, October 23, 2001.
2. 2000 Occupational Employment and Wage Estimates, Arizona Department of Economic Security, Research Administration, Internet Edition, March 2001.
3. "Arizona Nursing Profession Statistics Versus U.S. Averages" Internet report of the AzHHA Healthcare Institute, October 30, 2001.
4. "Arizona's Workforce Shortage," Internet report of the AzHHA Healthcare Institute, August 2001.
5. "Nurse Shortage Worse in Arizona," Inside Tucson Business, Kyle, Schliesman, Internet Edition, October 23, 2001.
6. "NURSING WORKFORCE: Emerging Nurse Shortages Due to Multiple Factors," GAO Report to the Chairman, Subcommittee on Health, Committee on Ways and Means, House of Representatives, July 2001, pgs. 6-10.
7. Ibid.
8. "Where's the nurse? Staffs stretched too thin." American Medical News, Internet edition (amednews.com), Stephanie Stapleton, June 18, 2001.
9. "Salaries of nurses around the world," THE TIMES, (e-services edition) August 17, 2001.
10. "Where's the nurse? Staffs stretched too thin." American Medical news, Internet edition (amednews.com), Stephanie Stapleton, June 18, 2001.
11. "NURSING WORKFORCE: Emerging Nurse Shortages Due to Multiple Factors," GAO Report to the Chairman, Subcommittee on Health, Committee on Ways and Means, House of Representatives, July 2001, page
12. "Occupation Report--Ranked Wages," America's Career InfoNet, Internet Report of U.S. Department of Labor, November 15, 2001.
13. "What's Going On," Barbara B. Gray, MN, RN, NurseWeek, Internet edition, February 12, 1998, page 1.
14. A prevailing wage as it relates to alien certification is an average wage determined by the U.S. Department of Labor from its national Occupational Employment Survey (OES) for the local area of the employer. Employers who need to know the technicalities of prevailing wage application should contact the alien labor certification unit of the DES Employment and Training Administration.
15. Russell Ahr telephone interview, November 15, 2001.
16. "Code Blue: Crisis in the ER," Nancy Shute and Mary Brophy Marcus, U.S. News & World Report, September 10, 2001, page 59.
17. "National Preparedness: Ambulance Diversions Impede Access to Emergency Rooms," Rep. Henry A. Waxman, report of Minority Staff, Special Investigations Division, Committee on Government Reform, U.S. House of Representatives, October 16, 2001, pages 4 & 12.
18. "Code Blue: Crisis in the ER," Nancy Shute and Mary Brophy Marcus, U.S. News & World Report, September 10, 2001, page 59.
19. "Nurse shortage throwing Tucson hospitals into crisis." The Associated Press, The Arizona Daily Wildcat Online, September 25, 2000.
20. "Shortage of nurses target of task force." Jane Erickson, Arizona Daily Star, Internet edition, May 9, 2001.
21. "HHS Awards $27.4 Million to Address Emerging Nursing Shortage," U.S. Department of Health and Human Services, HHS News, Internet edition, September 28, 2001.
22. Ibid.
23. "Bills aim to increase number of nation's nurses," Gina Shaw, American Medical News (via amednews.com), June 11, 2001.
24. "Immediate Passage of Nurse Reinvestment Act Deemed Essential by National Health Care Group," Maureen Knightly, The Briefing Room (an Internet page of the AHCA), October 3, 2001.
25. "Prescription for nurse shortage: cash," Liz Kowalczyk, The Orange County Register Internet edition (ocregister.com) October 28, 2001.
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