Correspondence
The Nursing Shortage and the Quality of Care
N Engl J Med 2002; 347:1118-1119October 3, 2002
- Article
To the Editor:
The findings reported by Needleman and colleagues (May 30 issue)1 provide further evidence of what hospital nurses have feared for quite some time: there are too few registered-nurse (R.N.) staff members, and there is too little support to provide safe and beneficent care for patients. Although there is no simple fix, change may come too late and at too high a price. As hospitals balance the costs of technological means of delivering care with the costs of hiring more nurses, the cost–benefit calculation is not in nurses' favor. Nurses are compassionate, altruistic providers, yet they have not successfully met the challenge of costing out their productivity and remain financially undervalued.
Financial compensation alone, however, may not reduce the dissatisfaction and stress that nurses experience; other supportive measures are critically needed. As ethical, genetic, and technological challenges associated with the provision of care demand our attention, the need for nursing expertise will escalate. The research of Needleman et al. should give us pause for ethical reflection. As Peter Drucker noted, “There is nothing less productive than making more efficient that which should not be done at all.”2 Reducing staffing ratios and having fewer R.N.s on staff may be efficient and may reduce expenses, but at what cost to patients? All health care providers must advocate urgent change within the system. Creative strategies and further research are warranted to find new solutions to these difficult problems. Hospitals need intelligent, educated, and dedicated nurses, but nurses need support. It is time nurses were rightfully recognized, respected, championed, and — yes — financially compensated.
(The opinions expressed in this letter are those of the authors and do not necessarily reflect the policies of the National Institutes of Health and the Public Health Service or the Department of Health and Human Services.)
2 ReferencesConnie M. Ulrich, R.N., Ph.D.
Gwenyth Wallen, R.N., Ph.D.
Christine Grady, R.N., Ph.D.
National Institutes of Health, Bethesda, MD 20892
culrich@cc.nih. gov 1
Needleman J ,Buerhaus P ,Mattke S ,Stewart M ,Zelevinsky K . Nurse-staffing levels and the quality of care in hospitals. N Engl J Med 2002;346:1715-1722
Full Text | Web of Science | Medline2
Drucker PF. Managing for the future: the 1990s and beyond. New York: Dutton, 1992:198.
To the Editor:
The American Nurses Association commends the Journal for publishing the research on the impact of nurse-staffing levels and for bringing the issues facing nursing to the forefront. In addition to the potential solutions mentioned in the article, there is Nursing's Agenda for the Future, a strategic plan representing the shared vision of more than 60 nurses' organizations that have put forth strategies to address the complex, interrelated factors behind the nation's growing shortage of nurses.
This shortage, projected to reach unprecedented levels by 2010, is the result of a confluence of demographic, economic, and cultural factors. If the problem is left unattended, health care consumers can anticipate a decline in access to care and in the quality of care — just as baby boomers reach an age at which they will demand more health care services.
For this reason, the nursing community has united around a shared vision for the future of the profession and has developed a comprehensive strategic plan to address the nursing shortage and the factors driving it. Nursing's Agenda for the Future focuses on strategies that will move the profession forward while ensuring that consumers have access to high-quality nursing care. Through Nursing's Agenda for the Future, we hope to join with other stakeholders in strengthening the profession, thus ensuring that consumers will continue to have access to high-quality nursing care and a safe health care environment.
Mary E. Foley, M.S., R.N.
American Nurses Association, Washington, DC 20024To the Editor:
I certainly agree with the findings reported by Needleman et al. and with Steinbrook's discussion (May 30 issue) of the issues underlying the nursing shortage,1 but I would like to interject another important perspective. Although we all agree that the nursing shortage has significant consequences for health care outcomes, there are two different approaches one can pursue in addressing the nursing crisis. The first approach is to increase the recruitment of nurses. Factors affecting recruitment include the number of nurses entering the profession and their willingness to work in the hospital setting. The second approach is to improve the retention of nurses. The factors affecting retention are related to the workplace environment and to feelings of value and respect. This is a multidimensional problem, encompassing issues related to scheduling, workload, and responsibilities for patient care. In this regard, one often-overlooked factor is the day-to-day relationships nurses have with physicians. A disturbingly high number of nurses decide to leave their hospital jobs because of less than satisfactory relationships with physicians.2 Before we recruit more nurses, we need to make it at least an equal priority to keep the nurses we have. In order to accomplish this task, all of us (physicians included) must take responsibility for addressing the underlying issues affecting nurses' job satisfaction and morale and do our part to improve the conditions and ambience of their work environment.
2 ReferencesAlan H. Rosenstein, M.D., M.B.A.
VHA West Coast, Pleasanton, CA 94588
arosenst@vha.com 1
Steinbrook R . Nursing in the crossfire. N Engl J Med 2002;346:1757-1766
Full Text | Web of Science | Medline2
Rosenstein AH . Nurse-physician relationships: impact on nurse satisfaction and retention. Am J Nurs 2002;102:26-34
CrossRef | Web of Science | Medline
To the Editor:
Steinbrook and others avoid tackling the primary dilemma within nursing. Nursing is not “an embattled profession,” as Steinbrook says, but rather an embattled vocational trade group, which is why promising, young, career-oriented students should be directed away from nursing.
Approximately 75 diploma training programs, involving little or no college study, provide preparation for the nursing workforce. Similar programs train vocational workers, who receive a salary commensurate with their apprenticeship.
Approximately 900 junior colleges educate the largest number of entry-level nurses. Graduates of junior colleges are called “assistants” (e.g., dental assistant, physical-therapy assistant, engineering assistant, or computer-network assistant). Only nursing maintains the hypocrisy of allowing these graduates to have the same title as students who pursue a bachelor of science degree in nursing (B.S.N.), offered by more than 500 universities. In no other career group do graduates of vocational schools, community colleges, and universities lay claim to the same licensure.
Salaries are commensurate with education and experience, except in nursing; all nurses are lumped into one category and paid at the lowest denominator. Most nurses have only a two-year associate's degree or a diploma from a three-year vocational program. The salaries of the nursing workforce reflect this low standard of education. At the heart of the poor image of nursing, the nursing shortage, and disharmony within this vocational trade group is the lack of a B.S.N. requirement for entry-level positions in nursing.
Christy A. Price Rabetoy, N.P.
Nephrology Associates, Salt Lake City, UT 84107To the Editor:
As one solution to the shortage of registered nurses, I would suggest a return to the hospital-based nursing program. Not every young person feels the urge to go to college to receive a B.A. degree in nursing or has the money to pay for such a program. The subsidized hospital-based program of old was the mainstay of nursing training, and these programs produced excellent bedside nurses. This is what we need again.
Bernard H. Miller, M.D.
Chesapeake Internists, Chesapeake, VA 23320- Citing Articles (1)
Citing Articles
1
Ada Spitzer, Didier Camus, Cécile Desaulles, Nicolas Kuhne. (2006) The changing context of Western European healthcare systems: Convergence versus divergence in nursing problematics. Social Science & Medicine 63:7, 1796-1810
CrossRef
