Photos by Alan Lessig / The Detroit News Elnora Spencer has worked in the critical care unit at Henry Ford Hospital in Detroit for 10 years. She says nurses there have the shifts they need to make their lives work. “I love my job, I really do,” says Spencer.

Nurses’ Rx: More pay, less stress

Better conditions needed to attract, retain RNs

Nurse Eusebia Aquino-Hughes, foreground, and nurse Florence Tirador of Providence Hospital in Southfield pray before their shift in the hospital chapel. Aquino-Hughes says the hospital is trying to improve working conditions.

By Sarah A. Webster / The Detroit News

    DECKERVILLE — Earlier this year, the 15-bed community hospital in this rural town announced it would cut about four of its 20 registered nursing positions to save money.

    The nurses thought the cuts would be too deep and compromise their ability to provide quality care to patients. In June, all but one nurse quit in protest.

    With a widespread shortage of nurses, the Sanilac County hospital was unable to find the seven nurses it would need to stay open on a skeleton crew. It had to stop admitting patients and treating emergencies, referring the town’s 1,015 residents elsewhere.

    “I think that it has brought to a very small hospital the issues that the nursing shortage is ultimately going to have for a number of hospitals,” said Ed Gamache, administrator of Deckerville Community Hospital.

    The dispute with the nurses was settled the following month. The hospital not only backed away from the cuts, but also provided increased pay for night and weekend shifts and gave nurses a powerful voice in administrative issues.

    “What we had to do was find what would be appealing enough in terms of pay and structure that we could recruit nurses back,” Gamache said.

    “If there is a proposed change that a single nurse simply can’t live with, then we will figure out what we need to do to overcome it.”

    The Deckerville dispute holds some prescriptions for health care officials grappling with a growing nursing shortage. The cure may be as simple as improving working conditions for nurses, health care experts say.

    But in an era of managed health care and financial constraints, it may be difficult for hospitals to recruit new nurses or keep others from defecting from a profession known for low pay, inflexible hours, increased stress and dismissive treatment.

    Past nursing shortages were largely addressed with federal and local campaigns to improve the image of nursing and recruitment drives, including attracting nurses from other countries. Those strategies, which experts say are again needed, have usually worked in the short-term but have never been lasting.

    For example, a law that eased the licensing transition for Canadian nurses into Michigan has brought some relief to hospitals in downtown Detroit and other border towns. However, there is now a global shortage of nurses and few experts believe foreign nurses will be a reliable source of workers.

    The U.S. Congressional Research Service said eliminating the shortage with foreign nurses would “require immigration on an unprecedented scale,” comparable to what happened when Congress increased the number of special immigration visas for professional workers.

    Practical long-term solutions for this nursing shortage must involve fundamental improvements in nurse working conditions, according to the U.S. General Accounting Office and Public Sector Consultants, who studied the nursing shortage for the Michigan Department of Consumer and Industry Services.

    Key issues identified in these reports include:

* Staffing levels that allow nurses to do their jobs properly;

* Including nurses in administrative decision-making;

* Fair and flexible scheduling, with extra compensation for off-time shifts;

* Pay commensurate with the level of responsibility and educational level. There is currently no distinction in salary between staff nurses with 2-, 3- and 4-year degrees;

* And independent billing. Nurses complain that their services are lumped into a hospitals’s room charges, rather than billed separately like other professionals. Many nurses consider this degrading.

    Directly addressing these issues will require collaboration among nurses, physicians, hospitals and payers, and may reduce the likelihood of nurses leaving the field and encourage more young people to enter the profession, government experts say.

    These changes would also help the recruitment of more men and minorities, which many nurses say will be necessary to ease the nursing shortage.

Magnet hospitals

    Healthcare experts say it is clear that better working conditions can have a positive effect on retention and recruiting.

    Aside from examples like Deckerville, they point to hospitals with exceptional working conditions. Designated as “magnet” hospitals by the American Nurses Association (ANA) after an intensive evaluation, these hospitals do not have serious staffing difficulties.

    The length of employment for a nurse at a magnet hospital is twice as long as non-magnet facilities, and they have less difficulty recruiting new nurses. More important, patient care appears better — lower mortality rates, shorter length of stays and higher satisfaction reports.

    “It’s an excellent place for a nurse to work, for a patient to be treated,” said Kammie Monarch, director for accreditation and the magnet program at the nation’s largest professional organization for nurses.

Allison Renaud, left, a nurse from Canada, talks with Joyce Farrer, director of nursing at Henry Ford Hospital, during a recent job fair in Windsor to attract Canadian nurses to work in Metro Detroit.

    Thirty-six hospitals in 18 states have magnet designation, but none are in Michigan.

    Don Potter, the president of the Southeast Michigan Health & Hospital Association, called the magnet designation a political tool of unions and downplayed its importance. The ANA’s subsidiary, United American Nurses, is a labor union.

    Improving staffing levels, which reduces a nurses’ workload, has also had a positive effect on nursing shortages. When the state of Victoria in Australia enacted minimum nurse-to-patient ratios in 2000, there was a 10 percent surge in nurses returning to the profession.

Staffing levels

    In America, however, fixing working conditions is proving more challenging. One reason: there is little agreement between hospital administrators and nurses on what constitutes safe staffing levels — the primary working concern of nurses.

    California has fought over the issue since 1999, when Gov. Gray Davis signed a Safe Staffing Law. The state health department is charged with defining minimum patient-RN ratios for when the law takes effect in 2002, but thus far has been unable to reach a consensus.

    Experts studying the nursing shortage in Michigan said lack of data on appropriate staffing levels is a key problem.

    “There are no standards for either minimal or optimal staffing ratios or nurse-to-population ratios. Guidelines are limited for determining appropriate nurse staff mix in appropriate situations,” concluded Lansing-based Public Sector Consultants in a study for the state this year.

    As it stands, hospitals create their own formulas for defining staffing levels, but nurses say they are confusing and unsound. The Joint Commission on Accreditation of Healthcare Organizations, which oversees the minimum standards of hospitals, offers little to no guidance on this issue.

    Currently, hospitals must show only that they have a staffing plan and a budget to support it, said Carol Gilhooley, director of accreditation process improvement for the Joint Commission.

    But that may soon change. The Joint Commission, which bases its standards on evidence, is studying appropriate staffing in a pilot program that may set forth changes. Joint Commission officials, however, noted that they are unlikely to endorse ratios.

    “There is a lot of clinical outcome indicators ... that are sensitive to how well an organization staffs, not just numbers, but their competency and skill mix,” Gilhooley said. She said there is also an impact on patient care when there are shortages in non-nursing areas, such as housekeeping.

Reaching out

    Many staff-strapped hospitals are already trying to correct their recruitment and retention shortcomings.

    “We really tried to listen to staff and said, ‘What’s bugging you?’” said Steve Velick, an official with Henry Ford Health System and former chief executive of that company’s flagship Detroit hospital.

    Many facilities now permit nurses to write their own schedule, although that increases their reliance on temporary agency nurses and causes them to juggle their existing pool of nurses between departments.

    Many hospitals also found that their new nurses were quitting after about a year of service, and most have now implemented mentoring programs to help ease new nurses into the stressful career. Botsford General Hospital in Farmington Hills, for example, has 15 pairs of new and experienced nurses teamed up in such a program.

    “Sometimes all you want to say is, ‘God, I’m having a bad day,’ ” said Deborah Luchini, a new nurse whose mentor Colleen McKay has been on the job for more than two decades. “You can just feel overwhelmed.”

    Some hospitals are even reaching out to nurses who’ve quit and inviting them to come back.

    St. John Health System of Detroit recently began a 10-week nurse refresher course for nurses who have left the profession and would like to return. The hospital is paying for all expenses, including books, in return for a one-year commitment of at least two work days a week. More than 80 nurses have enrolled.

    “Our suspicion is that there are a huge number of licensed nurses that have stopped practicing and probably a good number of them would never return,” said MaryAnne Rizza, a nurse recruiter for St. John. Despite that, even a modest number of return nurses “would give us immediate results,” she said.

    Some nurses feel their hospitals are working hard on these problems and some nursing units said they do have good working conditions.

    “They do the best they can, and I mean it sincerely,” said Eusebia Aquino-Hughes, a nurse at Providence Hospital and Medical Centers in Southfield. “They really try to accommodate you.”

    More than 70 percent of the nurses in the critical care unit at Henry Ford Hospital in Detroit have worked there more than five years.

    “You have to feel like you can accomplish the job,” said Kathleen Vollman, a clinical nurse specialist in that unit. “People have left for bonuses elsewhere, but they usually come back.”

    Elnora Spencer, who has worked in that unit for 10 years, said, “We have the shifts we need to make our real lives workable.”

Union solution

    But some nurses accuse hospitals of making token improvements and paying working conditions only lip service. Absent the improvements they desire, many of these nurses are turning to unions for solutions that they say help nurses and protect patients.

    Nurses in Flint, for example, went on strike until they received restrictions on mandatory overtime. Mandatory overtime is a major complaint of nurses, and one national survey indicated RNs work an average of 8.5 weeks of overtime a year.

    Lobbying pressure from nurses unions has led to the introduction this month of a bipartisan bill in Congress called the Safe Nursing and Patient Care Act, a bill that would limit overtime except in national emergencies.

    Many nurses say all they really want from their work environment is the ability to do their job properly and be respected and valued.

    “Monica Lewinsky gets more respect than nurses do,” complained Aquino-Hughes of Providence.

    Yet “the people who deliver care are the health system’s most important resource,” the Institute of Medicine said in a follow-up to a heralded 1999 report on medical errors. That study concluded that as many as 98,000 hospital patients die annually because of mistakes, many of which are caused by nurses.

    Many nurses feel that respect is inextricably tied to the image of nursing, and they worry that the public lacks a true understanding of the hard, scientific work they do or its rewards.

    “It takes a lot to be a nurse, and to remain a nurse,” Aquino-Hughes said. “It’s like doing God’s work. I feel religious about nursing.”

    “I love my job, I really do,” added Spencer of Henry Ford. “There are times that are ugly, and every three years, I threaten to quit. But realistically, this is the right combination of things for me. There is nothing more wonderful that seeing somebody come back to life.”