Local hospitals are waging a costly war that they are losing, one in which their success or lack thereof will have a marked impact on the quality of patient care a bidding war for nurses. Nancy Davis, chief nursing officer at Ochsner Health System, spends much of her workday trying to recruit nurses locally, across the country and worldwide. Even though Ochsner was one of only three hospitals in the New Orleans metro area to remain open during and after Hurricane Katrina, Davis still lost 65 percent of her nursing staff. Since the storm, she says, there hasn't been a net increase in the number of nurses available. Davis blames part of this on the negative national press New Orleans receives (potential workers don't want to move to the city) and the fact that nursing schools aren't supplying enough graduates. These factors, she says, have resulted in a costly bidding war between local hospitals for essentially the same pool of nurses. It also means that patients who normally would be admitted to hospitals are forced to spend hours and sometimes as long as a day waiting in the emergency room for a bed to open up.
Davis says the shortage is occurring at a time when area hospitals are already reeling financially.
"It's dire," she says. "I've been in New Orleans nursing leadership roles since 1977, and it's the longest-running and widespread shortage that I've seen in all that time. Nursing shortages nationwide tend to go in cycles, so it's not something that we're not used to, but this one, for all the environmental causes, has been sustained and devastating.
"The market dynamic here is that because of the shortage of nurses locally, there's been intense salary pressure. All the hospitals that are open have had to come up with different strategies to eliminate their higher priced agency nurses."
Agency nurses are those who are hired out by employment agencies. The agencies have a pool of nurses, local and traveling nurses that fill in the gaps for hospital nursing vacancies. The agency gets paid, the nurse gets paid, and that means the hospital is paying about double what a full-time employee would cost, according to Davis. Still, in order to keep rooms open, Ochsner and other hospitals have used the agencies.
Besides employment agencies, local hospitals also offer overtime to nurses to cover vacancies and have started their own nursing pools of former employees or other qualified local nurses that aren't looking for full-time work and will accept a slightly higher hourly rate in exchange for no employee benefits. Because the nursing shortage is nationwide and shows no signs of abetting the federal government's Health Resources and Services Administration (HRSA) in an April 2006 report projected a shortage of 1 million nurses by 2020 local hospitals are looking beyond the United States for nurses.
Davis recently hired 100 nurses from the Philippines. These are registered nurses with four-year baccalaureate degrees and are American board certified. They are also, as Davis puts it, stuck in "the morass of immigration paperwork." The nurses should start filtering into Ochsner sometime in the last quarter of this year and into 2008.
East Jefferson General Hospital (EJGH) also recently acquired the services of 100 Filipino nurses. The long wait time for these new hires frustrates Janice Kishner, chief operating officer and chief nurse executive at EJGH.
"If we could get some relief with the immigration, that would ... not solve the shortage, but help ameliorate the shortage problem," she says.
Like Ochsner, EJGH has been open since Katrina and has lost many nurses. Kishner says there was a shortage before the storm, but nothing like the current situation.
"Prior to the storm we had a vacancy rate of 2 to 3 percent, which translates into 25-30 nurses," Kishner explains. "Since the storm, our vacancy rate is 100-120 nurses, which is a 12 percent vacancy rate." Kishner stresses that the vacancy rate doesn't mean all of the open positions at EJGH are vacant. Contract nurses, traveling nurses and overtime are filling some of the positions temporarily. Nevertheless, the shortage has forced EJGH to keep some beds closed when there aren't enough nurses to attend to them.
Corresponding with the 12 percent vacancy rate is a 12 percent raise in nurse salaries at EJGH since Katrina. Like Davis at Ochsner, Kishner says there aren't many nurses moving into the area, so salaries will continue to increase. According to Barbara Morvant, executive director of the Louisiana State Board of Nursing, which licenses registered nurses in the state, there were 8,643 registered nurses residing in Orleans and Jefferson parishes in 2005 (3,511 in Orleans and 5,132 in Jefferson). By the end of 2006, that number decreased to 7,099 nurses (2,100 in Orleans and 4,999 in Jefferson).
"Orleans Parish definitely has shown a loss of registered nurses," Morvant says, "so as the population rebuilds, the number of nurses will be a concern."
Touro Infirmary, which reopened in late September 2005, has decided not to bring in nurses from overseas, but instead has focused its recruiting efforts on new nursing graduates and relocating nurses to the New Orleans area. In order to spur recruits' interest, Touro offers a $12,000 signing bonus and other incentives to nurses with at least two years' experience who are willing to sign a two-year contract. For new graduates, Touro will give monetary assistance for student loans and other incentives. Since 2006, the hospital reports it has hired more than 120 new nursing graduates. Touro hopes to hire 90 more registered nurses.
In order to entice local nursing school graduates to remain in the metropolitan area, hospitals maintain close relationships with local nursing programs. They provide locations for students to complete their internships, and many hospitals give scholarships to top students.
The strategy seems to be paying off. Dr. Demetrius Porche, the new dean of LSU's Health Sciences Center (LSUHSC) New Orleans School of Nursing, says that most of LSU's graduates are staying in the area.
"Last semester when we graduated our class, we lost seven students (who went) out of state," Porche says. "But this semester, we only have three going out of state."
The LSUHSC program is the area's largest with 752 students, and the majority are seeking a bachelor's degree in nursing or a master's degree. For the 2006-2007 academic year, the school plans to graduate 172 students with bachelor's degrees and 59 students with master's degrees. That's the good news.
The bad news is that even with a tremendous need for more nursing students, LSUHSC has to turn down many qualified applicants. For the upcoming school year, 442 qualified applicants who met all of the requirements for the program applied to LSUHSC's nursing school, but only 217, or 49 percent, were accepted.
"Basically, it's not having enough faculty or not having enough clinical sites, especially post-Katrina," Porche explains. "The main one is the clinical instructors."
The scarcity of nursing faculty is something being felt around the country, and it's getting worse. A recent National League for Nurses report says, "One in five nurse faculty members said they were likely to retire from paid employment in five years or less; and almost one-half of all nurse faculty (47.9 percent) said they were 'likely' to retire in six to 10 years."
Not only are the instructors graying Porche says the average age is 52 years old but the bigger problem has to do with salaries. Most nursing schools require an instructor to possess at least a master's degree and, according to the U.S. Bureau of Labor Statistics, the mean annual salary for a nursing instructor is $56,840. On the other hand, the mean annual salary for a registered nurse, who needs only a bachelor's degree at the most (not all registered nurses have bachelor's degrees), is $56,880. In this case, earning an advanced degree and becoming an instructor translates into less money.
Porche says nursing schools have been able to offer stipends through HRSA and the Louisiana Board of Regents to continuing graduate students so they can become instructors and teach at the schools from which they just graduated. It's not enough though. A recent news release from the American Association of Colleges of Nursing (AACN) points out that last year 42,596 qualified applicants were denied entrance into nursing programs, primarily due to a dearth of nursing instructors. The news release goes on to explain that the Bush administration's 2008 federal budget proposes sharp reductions in programs that financially benefit graduate nursing students.
Dr. Gail Tumulty, interim director of Loyola University's School of Nursing, says the shortage will continue and worsen as the years pass. "We don't see this one [nursing shortage] getting better any time soon," she says. "You have the aging of nurses, faculty, and you have the aging baby boomers, who will need more nursing as they approach the end of life."
Before patient care suffers, hospitals will close down beds. Local hospital officials say they maintain certain nurse-to-patient ratios, depending on patients' needs, and they won't compromise those ratios. Kishner puts it simply: "Once the hospital's full, that's it. It's like a restaurant if you can only seat 40 people and there's 48 people, then eight people aren't going to eat."
It may not be a good analogy. In the case of a restaurant, someone doesn't get dinner that night. In the case of a hospital, someone doesn't get care when they might really need it.