Concern about the nationwide shortage of nurses is being expressed by nearly all those involved in health care. Everyone, including the federal government, is looking for solutions to the problem. While all areas of nursing are involved, the specialty of critical care nursing has been one of the hardest hit. In fact, 82 percent of hospitals, in a 1986 survey by the American Hospital Association, reported difficulty finding enough nurses in this field. Today, there are an estimated 1 million-plus registered nurses in the U.S., but by the year 2000, federal statistics project a shortage of more than 600,000.
What is causing the shortage, and what can be done to relieve it? The problem and solution are the same: recruitment and retention.
Nursing school enrollments have steadily fallen for many years. Statistics from the National League for Nursing indicate that enrollments are down an average of 20 percent since 1982.
A change in cultural values is one major reasons. A recent survey of students entering college indicated that they are interested in careers associated with status, power and money. Obviously, nursing does not come to mind.
Another problem is the outdated image of nursing. If a young person's only view of the role a nurse plays comes from watching television and other media, it's no wonder he or she isn't interested in such a career. Nurses' relationships with family and patients are often presented as adversarial and negative. Recently, there has been a series of media portrayals of nurses as nymphomaniacs, drug addicts and mercy killers -- not an accurate or positive view. Most significant, the media depict nurses as "handmaidens" to physicians, with no independent thought or capabilities.
In reality, nurses are highly skilled, educated professionals; registered nurses have passed a national licensing examination, while specialty nurses usually have additional education and certification.
In critical-care nursing, there is a part of the practice that is "dependent" (i.e. determined by doctor's orders), but there is another component that is independent. While caring for a hospital's sickest patients, the critical-care nurse is an advocate for the patient and family, well-versed in lifesaving technology and willing to take responsibility for crucial decisions.
Nursing has traditionally been a female-dominated profession, but today's young women have many other career options. If a gifted student is interested in health care, it is likely that parents and guidance counselors may dissuade her from nursing and encourage an interest in other disciplines.
Not only is attracting qualified individuals harder than before, keeping good nurses is a persistent problem, for several reasons. Critical-care nurses are exposed to more occupational hazards than ever before -- from acquired immune deficiency syndrome to X-ray radiation, caustic substances and infectious agents. The stress of working in such an intense environment is unending. Nursing practice is very demanding, both physically and intellectually. Although the energy and attention expended are not easily visible, nursing care delivery is a very thoughtful process.
Salary also continues to be an issue. The national average salary for entry into nursing practice is $21,000. However, after 10 years of practice a nurse's salary is only $27,000. Contrast these salaries with what physicians earn -- often from $50,000 to more than $250,000 per year.
Salaries should reflect the responsibility and education of the individual. A physician who performs a cardiac transplant probably has an annual salary of several hundred thousand dollars. There is no doubt that such doctors earn that salary and perform surgery that very few people can; undoubtedly, they save lives. But what happens to that patient when the surgery is completed?
That patient is brought to the intensive care unit, where nurses provide care that supports the patient's life. The nurse is with the patient 24 hours a day, seven days a week, to monitor vital signs and responses. If a critically ill patient's blood pressure drops, someone must intervene instantly. There frequently is not time to place a phone call to the physician and receive orders. For that reason, most critical-care nurses work with established clinical protocols so that the safety of the patient can be supported.
Most physicians understand the importance of nurses and recognize that their surgical or medical skill would be useless if not for the constant assessment and intervention of the nurse. Critical-care nurses save and preserve life, but for a considerably smaller salary than physicians receive.
We must give equal time to the issues of retention and recruitment. Salaries and working conditions must be improved. No one is advocating six-figure salaries, but we are suggesting salaries that are more in line with the profession's responsibilities. Other conditions that should be addressed include adequate support services within the hospital setting, better benefits and greater involvement of nursing professionals in decision-making.
Many major nursing organizations have launched programs to help recruit more nurses. The American Association of Critical-Care Nurses (AACN) is the first to announce a comprehensive program to recruit young people into the specialty of critical-care nursing. With this program, our members will be going into schools of nursing, high schools, junior high schools and grade schools to talk about nursing as a career.
As we care for someone with a life-threatening illness, as we ease pain, intervene to avert a crisis and help a family adjust to the realities of critical illness, we know we make a difference.Jeanette Hartshorn, RN, PhD, is president of the American Association of Critical-Care Nurses. She teaches at the College of Nursing, Medical University of South Carolina in Charleston.
A free brochure on careers in critical-care nursing, "Make the Critical Difference," is available from the AACN, One Civic Plaza, Newport Beach, Calif. 92660.
Second Opinion is a forum for points of view on health policy.