When Regina Cusson became a nurse, she went to work in a hospital, “on a floor with very sick people” and wide variety of complaints. Now the dean of the University of Connecticut School of Nursing, she says that’s what new nurses did when they began their careers in the 1970s, a period of big growth for the sector.
But on May 11, when she sent off the graduating class, she knew few of the new nurses would take her path.
“The jobs that are available in the marketplace are geared much more to specialty practice,” Cusson said.
She said there’s work for nurses dermatologists’ offices, outpatient clinics, rehab centers and lots of other places. But there isn’t always work in hospitals, even as 8 million people have signed up for insurance under the Affordable Care Act.
Forget what you’ve heard about expanded schooling solving the nursing shortage. Ignore that nursing is the fastest-growing industry in the country. The fact is that nurses aren’t flocking to work in hospitals — and right now, we need them there.
Indeed, in hospitals, the total nationwide workforce — of which nurses represent the biggest chunk — has been hovering between 4.7 million and 4.8 million since the beginning of 2011, according to the Bureau of Labor Statistics, even as patients are increasingly ending up in hospitals for care.
Despite growing during the recession, hospital staffing has stayed within a narrow band since early 2011 and essentially stalled since early last year. At the same time, patients have increased some dimensions of usage. Data for the past two months is preliminary.
Data on overall hospital utilization are often a few years behind, but it’s clear that utilization of some parts of the hospital is up this year. For instance, 73 percent of emergency rooms reported that their patient populations had stayed the same or increased since the beginning of the year, according to a survey by the American College of Emergency Physicians released on May 21. It doesn’t seem to just be population growth either: The survey revealed that more of the patients are on Medicare, which expanded in many states under the ACA, and they’re often sicker than in the past.
Hospital utilization has increased since the beginning of the year, according to data released on May 21 by the American College of Emergency Physicians. The increase seems at least partially linked to the implementation of the Affordable Care Act, as it included an increase in Medicare patients.
In other words, even as fewer new nurses join hospitals, patients have been increasingly heading to the hospital. And since nurses are often patients’ most reliable point of contact, that usage–staffing mismatch can be unsafe, according to Deborah Burger, president of the union National Nurses United, which has been pushing for legislation that would establish minimum staff-to-patient rations across the U.S.
“We’re concerned about the general safety of patients,” Burger said. Her organization said bad outcomes can mean patient deaths, post-operative complications or just slow care.
Like so many recent shifts in health care, at least part of the reason that nursing staff levels and patient levels are heading in opposite directions seems to be the ACA, also known as Obamacare. Peter McMenamin, a senior policy fellow at the American Nurses Association, said hospitals are holding off on hiring above replacement levels in large part because of the structural changes in the ACA.
“Hospital chief financial officers are not in ‘Chicken Little’ mode, but there’s always some catastrophe coming right around the corner,” said McMenamin. “Right now there’s a possibility that there’ll be cuts in Medicare because of the Affordable Care Act. There’ll be penalties for readmissions. They’re worried there’ll be challenges to their revenues.”
Unfortunately, this uncertain, thin-margins period for hospitals is colliding with a coming wave of retirements. In the next decade or so, 1 million registered nurses will be coming up on retirement, according to Donna M. Nickitas, editor of the journal Nursing Economic$.
And short staffing accelerates nurses’ exits from hospitals.
“Insufficient nurse staffing in acute-care hospitals is raising the stress level of nurses, impacting job satisfaction, and driving many nurses to leave the profession,” Nickitas said.
That’s at time when inflation-adjusted federal funding for scholarships and loan repayment for nurses has fallen to about 25 percent of what it was in the early 1970s — when most of today’s retiring nurses trained. New nurses, who often have to pay $10,000 to $20,000 per semester of school, simply don’t have as much funding available to them as the nurses their trying to replace.
Indeed, despite a well publicized surge in the past decade in the number of nursing schools, the U.S. “turned away 79,659 qualified applicants from baccalaureate and graduate nursing programs in 2012 due to an insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints,” according to the American Association of Colleges of Nursing.
“Schools are struggling to expand capacity,” Nickitas said. And as long as they are, the projected growth in nursing may remain insufficient.
The ACA does emphasize primary and preventative care, which help keep the population more healthy and thus should reduce the burden on hospitals in the long term. The problem is that it’ll take years to train the physicians and nurse practitioners who can administer that care. The result is that millions have new insurance, but the hospital is still the only place to get many kinds of care — just-in-case stitches for that cut, that hip replacement (finally) or just a quick prescription for asthma medication if you’re worried that you might have an attack while waiting for the doctor’s appointment.
It’s not all doom and gloom. The BLS says we’ll be able to replace those who are retiring and will still be able to add about 530,000 nurses. In addition, as Pamela Austin Thompson, a senior vice president at the American Hospital Association, points out, patients do get more of their care outside of the white building with the red cross these days.
“Care is moving out into the community,” Thompson said. Instead of going to the hospital for a colonoscopy, for instance, patients may get the procedure done at an outpatient center. The same is true for physical rehabilitation or even minor surgeries.
“Patients are still getting the care, but they may not be getting it in the acute care environment because that’s really the most expensive environment we offer,” Thompson said.
Right now, though, it seems to be the environment into which patients have to go. As Thompson suggests, the nurse staffing and patient usage levels in the hospital could well balance in the long run, especially if primary-care providers — both physicians and nurse practitioners — are able to help Americans manage their long-term health complaints before they require a trip to the hospital.
But right now, nurses can do little to contribute to the increase in primary care that could ease the burden on hospital work. One reason limits on nurse practitioners. Another is that there aren’t enough primary-care physicians to work with. By 2020, we could be short more than 90,000, according to Association of American Medical Colleges. No primary-care doctors means no primary-care offices for nurses to work in.
Already today, many parts of U.S., both urban and rural, suffer from what the Human Resources and Services Administration of the Department of Health & Human Services calls a Health Professional Shortage Area. Shortages of primary-care providers are especially acute.
As Cusson, the dean of the School of Nursing at University of Connecticut, put it to the new graduates, it may be a while before the effects of the law and demand catch up to one another.
“This is a very unique time though that everyone expect there would be huge demand for nurses,” Cusson said. “But that is not happening — at least not in the jobs that nurses go into when they graduate.”