BY GAIL FRIEDMAN
PHOTOGRAPHY BY GARY WAYNE GILBERT
The call from
the intensive-care patient should have been routine. Problem was,
the nurse on duty wasn't an ICU nurse. Chris McManama '76 normally
worked either in labor-delivery or post-partum care, or sometimes
in the nursery. She'd been "floated" into the ICU that day to ease
a staffing shortage, a frequent practice in the midsize suburban hospital
near Boston where she worked. McManama answered the man's call promptly,
and searched for the button that would turn off the persistent flashing
light and beep. She scanned the maze of unfamiliar equipment, settling
on a blue button, expecting the light to halt. Instead, a team of
doctors, nurses, and therapists "came tearing in, out of breath, all
set up and revved to go," she recalls. McManama had pushed the "code"
button, the life-or-death alarm that alerts the staff to a patient
in cardiac arrest or other dire distress.
As it happens, the patient was fine. McManama, however, was not. "I
was humiliated," she says.
McManama, 47, never had to work another shift in the ICU. She went
on to complete 15 years on staff at the hospital, working every other
weekend, then became a per diem nurse, which let her dictate her hours
and spend weekends with her kids. After six years working per diem,
however, supervisors told her that weekend work was once again mandatory.
In 1999, with more than two decades of nursing experience, McManama
left the hospital--and her career--behind.
Though McManama doesn't know if a nursing shortage led to the weekend
work policy, it is a common practice, when hospitals have insufficient
staff, to compel nurses to work undesirable shifts. Pinched by a nursing
shortage, hospitals also commonly resort to mandatory overtime, float
nurses into understaffed areas, use more unskilled aides, and patch
together other staffing Band-Aids to make sure their beds are covered.
The result: seasoned nurses who worry about inadequate care, who spend
as much time overseeing unskilled assistants as caring for patients,
and who find themselves exhausted, sometimes to the point of burnout.
For McManama, while scheduling conflicts were the final straw, nursing
had become fraught with unanticipated stresses--not just the emotional
tug of dealing with sick patients but the fear of infection, the fear
of lawsuits. Particularly disheartening, says McManama, was watching
the experience of a seasoned colleague who was sued for malpractice.
"I saw this person get destroyed," she says. "I got out, I'm clean,
I didn't get stuck with a needle. Let's call it a day."
Though McManama seems content to have given up nursing, her decision
to leave was bittersweet. When she was working with new mothers, she
says, "Every delivery was pretty much a miracle."
Nursing shortages have worried health care professionals in this country
for decades--indeed, for as long as a century, writes Lois Friss of
the University of Southern California, in a 1994 article published
in the Journal of Health, Politics, Policy and Law. (The exception:
1930-41, during the Great Depression.) Solutions, Friss says, have
tended to focus on attracting new prospects. Federal money for nursing
education, wage increases, even image campaigns have eased shortages
from time to time. But strong demographic shifts contribute to the
crisis in nursing today, leading some academics and health professionals
to predict that the current shortage of hospital nurses will grow
in severity long before it abates. Already, the American Hospital
Association reports that 10 percent of budgeted nursing positions
are unfilled across the country, and that one in seven hospitals has
a serious nursing shortage. The U.S. Department of Health and Human
Services estimates that 114,000 RN positions will remain unfilled
Experienced nurses like McManama are leaving hospitals for a variety
of reasons--some because they are dissatisfied, others because they
find more lucrative nursing jobs in industry or pharmaceutical companies,
or better hours and less stress in doctors' offices. But the majority
of nurses who are expected to abandon the field in the coming years
will leave simply because they are too old to remain at the bedside.
In 1983, registered nurses younger than 30 made up 30.3 percent of
the nursing workforce; by 1998 they accounted for only about 12 percent,
according to a study by Peter Buerhaus, senior associate dean for
research at Vanderbilt University's nursing school. Within a decade,
Buerhaus predicts, more than 40 percent of RNs will be over 50. Baby
boom nurses will begin retiring in large numbers after 2007.
The problem is compounded by a steady decline in nursing school enrollment
that only recently has shown signs of improvement. Enrollment in bachelor's
degree programs dropped for six consecutive years, from 1995 to 2000,
according to the American Association of Colleges of Nurses (AACN).
Enrollments were up 3.7 percent in 2001, but still reached only 106,557,
compared to 127,683 in 1995, the year the current decline began.
Enrollments now appear to be rising across the country, as word gets
out about the nursing shortage and nursing's potential as a recession-proof,
secure job. (The U.S. Bureau of Labor Statistics has listed nursing
as one of the 10 occupations expected to have the most new jobs.)
The latest news is particularly encouraging at Boston College, where
the Connell School of Nursing reports a 41 percent increase in applicants
for the 2002-03 school year--rising from 230 to 324 potential students.
Applications to the Connell School had risen slightly in the previous
few years, but enrollment remained stagnant--47 in the 2000 freshman
class and 51 in 1999--because applicants weren't meeting the University's
academic standards, says School of Nursing Dean Barbara Hazard Munro.
In 2001, with a strong pool of 230 applicants, the freshman class
jumped to 67. In 2002, says Munro, with nearly 100 more applications,
the class could be up to 80--an improvement, but not as high as it
was in the early 1990s, when the freshman class peaked at 120 students,
and certainly not high enough to solve a staffing crisis that already
is squeezing hospitals.
One rapid solution to the nursing shortage would be an influx of male
nursing school applicants. But the image of nursing as women's work
repels many young men. (Think how much comedic mileage the movie Meet
the Parents got out of Ben Stiller's character, a male nurse.)
In fact, Munro says, most of the men who do enter nursing are not
typical 18-year-old undergrads but older students, more mature and
secure in their self-image.
While Boston College's nursing program plans to accommodate a larger
class next year, some schools have to turn away qualified students
because of a shortage in nursing faculty. Less than 2 percent of nurses
nationwide have a doctorate. "We're not cranking out the Ph.D. nurses
we need," says Munro. In both 2000 and 2001, the Connell School awarded
seven doctorates. Applications to Ph.D. programs nationwide haven't
increased over the past decade, Munro says, partly because the role
of Ph.D. nurses in clinical settings is limited, and because clinical
nurses tend to earn more than those in academia, where a Ph.D. generally
Carolyn Hayes, who completed her doctorate at BC in 1999, has been
a nurse of sorts since she was 13, giving her grandmother insulin
and listening to the Irish immigrant's colorful stories. In her neighborhood,
when a kid's tooth needed pulling, parents knew who could handle the
job. "I realized early on you don't just do something to people,"
says Hayes. "You have to be with them."
Now a nurse researcher at Brigham and Women's Hospital in Boston,
Hayes has been a bedside nurse and a specialist in end-of-life issues.
Describing her work with the dying, she dwells not on sadness, but
on the clarity of thought the dying can bring to the living. "There's
something about being with a person who doesn't care about the weather
report," she says. "It's very grounding."
When Hayes hears nurses at their breaking point, she says, it's never
because of a patient. Instead, she suggests, it is the erosion of
the nurse-patient relationship--due to mounting demands on nurses--that
drives some nurses away from bedside care. Monique Hapgood '93, who
is a nurse in the neonatal intensive care unit at UMass Memorial Medical
Center in Worcester and at St. Elizabeth's Medical Center in Boston,
also sees the trend. She remembers a BC professor who conveyed the
beauty of patient care so well, "you would have thought the backrub
was the best thing ever invented." Today "the new nurses don't even
know what a back rub is," Hapgood says, "nor would they have time
to give one if they wanted to."
Hospital patients who watch nurses change bandages or take blood pressures
don't always realize how much the demands of nursing have evolved.
Because outpatient clinics have siphoned off many simpler medical
procedures, hospital nurses now serve a never-ending stream of patients
who are much sicker than in years past. It used to be that when a
cardiac patient was discharged, says Hayes, the bed "would stay empty
for half a minute. Now a patient is lined up before the patient is
gone. There are more drugs, more intervention, more tasks, more technology,"
she says. But "there's a relationship there that nurses are hungry
to maintain, that patients need."
For Brianne Fitzgerald '71, the solution to stagnation has been to
seek variety within her nursing career. "You have to keep reinventing
yourself," says the public health nurse, who finds that changing jobs
from time to time keeps her fresh and hopeful. Fitzgerald works with
substance abusers and HIV-infected patients and with the health-care
providers who minister to them--a demanding job that can energize and
exhaust simultaneously. She has a master's degree in public health
from Boston University and recently returned from Botswana, where
she taught nurses and pharmacy technicians how to deliver anti-retroviral
drugs to the HIV-infected population. She has brought AIDS education--what
she calls AIDS 101--to communities in Namibia as well.
Fitzgerald says that nursing--a career she loves--suffers from a serious
image problem. Few realize its creative potential, that jobs like
hers stem from nursing. "That's the whole beauty--you can go from one
field to another: ICU, travel nurse, public health. If you could sell
it as a more creative field," she says, "more people would be interested
Part of the problem, as nurses are the first to say, is that nurses
tend to be self-effacing and even self-critical. Nurses "will tell
you what they didn't do on a shift," says Hayes. "I didn't do this,
I didn't do this. If they ever said what they were able to do--I was
able to help so-and-so--I would pass out cold."
Munro agrees: "We need to mouth off a little more, be more vocal about
our work." With physicians taking the lead role in explaining disease
to the sick and their families, she says, people seldom realize how
much the nurse in the ward accomplishes. When a nurse appears to be
having a friendly talk with a patient, "they think you're in there
having a chit-chat. They don't realize you made 10 assessments when
you were there."
The fact is, says Munro, that "being a caring, warm kind of person
is simply not enough"--if, indeed, it ever was. At the Connell School,
undergraduate nursing students in their first two years must take
life science chemistry, anatomy, physiology, microbiology, and pathophysiology--plus
several classes about nursing, in addition to meeting the University's
liberal arts requirements. Upperclassmen must attend clinical labs
and get hands-on nursing experience. Nurses tend not to broadcast
their training, says Hayes, "so the word doesn't get out. I blame
myself. I blame my colleagues. I blame the media."
The story of nurses such as Hayes and Fitzgerald who treasure their
jobs and have found stimulating career paths trickles slowly to the
public, compared to the bombardment of news about nurse burnout. (An
hour-long National Public Radio segment in January, for instance,
featured nurses and other health-care professionals lamenting hospital
working conditions.) But for all the nurses complaining bitterly,
there are many who continue to reap satisfaction not only from the
life-and-death challenges of the job but also from the extraordinarily
ordinary chores, like taking blood pressures and emptying bedpans.
The public doesn't hear much about the happy nurse.
The lucky ones
Count Lisa Gallagher among the many nurses who love their jobs. Gallagher,
who graduated from Boston College in 2000 and landed a job at Beth
Israel Deaconess in Boston even before she took her board exams, thinks
the pros of nursing far outweigh the cons. She rotates day shifts
and night shifts in labor-delivery--a plum unit that once was difficult
for new grads to walk into. Some days are harried and exhausting,
and at times she and a cohort think of their peers in less-challenging
jobs. "We joke around about being Gap girls and folding clothes,"
she says, but they never mean it. "After a 12-hour shift, I leave
and I feel a great sense of accomplishment."
Not to mention that Gallagher is bringing home far more in pay than
those Gap girls. The Bureau of Labor Statistics reports that hospital
RNs were earning $39,700 in 1997. Wages have frequently been a complaint
among hospital nurses and a precursor to strikes, but in many parts
of the country, nurses have reaped the benefits of long-fought battles
for better pay. The New York State Nurses Association has negotiated
contracts that give starting nurses more than $50,000 a year, reaching
over $90,000 with 25 years' experience. The profession has seen some
improvements in working conditions as well. After 13 weeks on the
picket line, nurses at Brockton Hospital in Brockton, Massachusetts,
for example, recently negotiated a contract that sets a limit on consecutive
overtime hours (four), and guarantees the right to refuse overtime
if they are sick or exhausted. Nurses, however, are far from united
on whether to unionize, and many nurses worry that it lends an unwarranted
blue-collar tinge to their public image. Gains, in any event, have
been uneven nationwide.
In Boston, home to several first-tier teaching hospitals, the situation
may be atypical. The city's major hospitals compete mightily for prime
nursing candidates, and at some institutions, newly minted BC nursing
graduates now enter in the $50,000 range, or close to it. Nurses with
bachelor's degrees from good schools are among the most sought-after
hospital employees--so sought after that rather than fighting for their
jobs, they are courted and find themselves almost untouchable when
it comes to cutbacks and layoffs. When Paul Levy, the chief executive
of Beth Israel Deaconess Medical Center, recently announced that the
hospital would lay off between 500 and 700 employees, he made it clear
that no nurses would get the axe.
It's an unusual day at work when Barbara Curley '73 has a washcloth
in her hand. Curley is an administrator--the director of quality management
and care management at Milton Hospital, just south of Boston--but when
staffing has gotten particularly tough, she's summoned up her RN skills
and bathed patients.
While Boston's big-name hospitals pluck the cream of the nursing crop,
smaller hospitals have a harder time attracting plum nursing grads.
Milton Hospital struggles to retain its nurses, keeping salaries competitive
with other community hospitals. Still, says Curley, "nurse managers
are providing more on-floor services. My patient advocate has ambulated
patients." Recruiting is particularly tough in the shadow of Boston's
health-care behemoths. "You're competing with other organizations
that are able to offer not only a more competitive salary, but flex-time
and day-care options," says Curley. Applicants for nursing leadership
positions routinely are asked about their ideas for handling the nursing
As large teaching hospitals tend increasingly to require RNs with
bachelor's degrees, Milton hires some nurses with associate degrees.
And the hospital fills several positions with registered nurses from
an agency, a costly alternative because the hospital must pay the
agency as middleman. "We want professional, baccalaureate-prepared
nurses to ensure high quality of care, but the reality is that sometimes
the goal has become challenging to achieve," Curley says. "We continuously
try to compensate to maintain a high level of care."
Curley blames the nursing shortage in part on the rapid elimination
of programs in hospitals that graduated "diploma" nurses. About 100
remain today, but more than 800 turned out nurses just 30 years ago.
Munro says there were seven in Massachusetts 11 years ago; one remains
in the state today.
The diploma programs typically are three-year, hospital-run training
grounds for nurses; in recent years many have paired with community
colleges to provide students with college credit. The hospital-based
programs have been eroding for years. As far back as 1948, the National
Nursing Council recommended ending them and creating B.S. degrees
in nursing at universities, according to Friss.
Once a major source of hospital nurses, diploma programs now account
for less than 10 percent of RN education programs nationwide, according
to the AACN. In 1980, about 55 percent of RNs were trained in hospital-based
programs, 22 percent had a bachelor's degree, and 18 percent an associate's
degree, according to the U.S. Department of Health and Human Services.
In 1996, 27 percent held only a diploma, and bachelor's-prepared RNs
accounted for 31 percent of nurses. The National Advisory Council
on Nurse Education and Practice, part of the federal Division of Nursing,
set a goal that at least two-thirds of nurses will hold a bachelor's
degree by 2010.
While it is generally accepted that college-educated nurses are best
prepared to handle the increasing complexity of health care, Curley
notes that hospitals cut their diploma programs without considering
the impact. They "eliminated the diploma programs without making any
type of adjustment or making provisions for who would provide bedside
care," she says.
At the same time, opportunities have increased for women outside nursing
as well as in nursing jobs that are far from the bedside--in pharmaceutical
companies, law, patient advocacy, and other arenas. "One of the most
critical flaws in the nursing profession now is the fact that we didn't
have the vision to strategically plan for what we enabled to happen
over the last 15, 20 years," Curley says. "We opened opportunities
for nurse specialists, minimized the importance of diploma clinical
nurses, and closed those programs. We neglected to figure out how
we're going to maintain the bedside nurse. That's why this nursing
crisis is going to be very different."
Some health professionals who see the potential for a public health
crisis believe government holds part of the answer. "I really believe
government intervention is necessary when the marketplace is not protecting
the public," says Sue Whittaker, associate director of state government
relations for the American Nurses Association (ANA). The Nurse Reinvestment
Act, passed in competing forms by the U.S. Senate and House of Representatives
late last year, is now awaiting a conference committee compromise.
In general terms, the act provides for student loan repayment, help
for hospitals to study methods for retaining nurses, and funding for
Several states in 2001 passed laws offering financial help for nursing
students. For example, Rhode Island law now forgives interest on nurses'
student loans; Texas provides grants to nursing programs to help them
increase enrollment; Oregon pays student loans for nurses who work
in underserved areas; and Virginia provides scholarship and loan repayment
Meanwhile, hospital working conditions have also been targeted by
governments, with mixed success. Fourteen states introduced legislation
in 2001 to limit or forbid mandatory overtime for nurses, but bills
became law in only New Jersey, Maine, and Oregon. According to the
ANA, the Maine legislation ensures that nurses are not disciplined
for refusing to work more than 12 consecutive hours and requires 10
consecutive hours off if there is overtime. Oregon's law prohibits
schedulers from requiring a nurse to work more than two hours past
a regular shift or more than 16 hours in a 24-hour period.
Efforts to directly address nurse-patient ratios have been the stickiest.
California's experience points to the inherent complexity of the issue.
In 1999, the state passed a law requiring regulators to set nurse-patient
ratios in acute-care hospitals by January 2001. The governor, realizing
regulators couldn't finish the unwieldy task in time, asked for a
one-year extension as soon as he signed the law.
BC nursing professor Judith Shindul-Rothschild views such quality-of-workplace
issues as paramount. "We must fix the intolerable working conditions
that nurses are facing," she says, "because if we don't do that, we
are going to burn them out as fast as they come into the system."
For educators, this also means teaching nursing students to ask the
right questions so they land at least their first jobs in facilities
where nurses face less hardship. At Boston College, Loretta Higgins,
professor and associate dean of undergraduate nursing programs, encourages
students to start their careers in a large teaching hospital, where
they are more likely to be mentored and face fewer of the staffing
problems challenging smaller hospitals. She advises graduates to ask
pointed questions of potential employers: How long is the orientation
program? How soon will they be put on nights without supervision?
When scheduling is reasonable and overtime optional, when salaries
are fair and the environment supportive, nurses have a chance to notice
the less tangible benefits of their career choice--the satisfactions
that lured many into nursing in the first place. "I can tell a nurse
he or she did an exceptional job," says researcher Carolyn Hayes,
"but when a patient puts a hand on a nurse's cheek and says, 'Thank
you,' it doesn't matter what I say."
Gail Friedman is a Boston-based freelance writer.