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Who will care?  Just as the largest generation of patients approaches old age, the largest generation of nurses prepares to retire.  Solving this nursing shortage  will take more than the usual staffing band-aids.
. photo of nurses with an infant


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 by 2015.

Image Problems
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 is required.

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 in it."

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 shortage.

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."

Going public
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 recruitment campaigns.

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 aid.

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.

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