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The nursing gap

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The nursing gap

Picture of Hiran Ratnayake
The nursing gap
News Journal (Wilmington, Del.)
Tuesday, September 30, 2008

Delaware is facing a serious nursing shortage that could compromise hospital care for a growing number of sicker, older patients.

The U.S. Health Resources and Services Administration estimates that the state will be facing a shortage of more than 3,000 nurses by 2010 unless significant changes are made. The situation hasn't yet led to inadequate patient care here, as it has in other states, hospitals say. But nurses remain concerned that patient care will be compromised if changes don't occur.

The state's shortage has several causes:

•Many nurses in Delaware soon will reach retirement age, and the challenges in the field, plus more opportunities in other careers, may deter younger nurses from remaining in nursing.

•Nursing schools in the state lack the capacity to produce enough new nurses to plug the gaps, with some maintaining waiting lists for admission even as demand for nurses continues to grow.

•The first baby boomers turned 62 this year and will begin putting more strain on the health system. A total of 13,052 registered nurses have active licenses in Delaware, but not all are practicing in this state.

Every Delaware hospital has unfilled positions for registered nurses. Nanticoke Memorial in Seaford has the highest vacancy rate, at 13 percent. That's followed by Beebe Medical Center in Lewes with 5 percent; Christiana Care at just below 3 percent; and St. Francis at 2 percent. Bayhealth Medical Center's two hospitals -- Kent General in Dover and Milford Memorial -- together have a vacancy rate of 1.8 percent. The Alfred I. duPont Hospital for Children's vacancy rate is around 1 percent. (Children's hospitals typically don't face the same pressure from nursing shortages because nurses gravitate toward pediatrics.) The national rate is 8.1 percent.

These vacant positions are typically filled by traveling nurses, who crisscross the state to fill gaps at short-staffed hospitals. They typically work at one hospital for three months before moving on to another.

Several studies have documented the dangers of inadequate nursing staffs, the most prominent being a 2003 report by the Institute of Medicine, which found that nurses in poor working conditions were contributing significantly to medical errors, including preventable deaths. Poor working conditions are defined by high patient-to-nurse ratios, mandatory overtime and fatigue on long shifts.

"Our state has been very lucky," said Penny Seiple, president of the Delaware Nurses Association. "Right now, we're doing better than a lot of other states. But unless we do things to make our environment better, it's going to be difficult to keep up with the need."

'You have to be the watchdog'

As the average age of patients has risen, so has the workload for nurses, said Loretta Ostroski, a registered nurse who helps manage Beebe's emergency department.

"With people living longer, you have higher volumes," she said. "Now there's a variety of medications for each disease process and we have to stay on top of the changes. We don't have much downtime."

One big issue is the increasing number of medications many older people are taking.

"When we're assessing and triaging patients, it's a lot easier to do that with someone who is taking two medications than someone who has 30 medications. It gets tricky when you're looking at what they're taking and what the doctor wants to give them," said Lindsay Decktor, an emergency room nurse at Beebe, which is treating a growing number of retirees.

"You have to be the watchdog over everybody," said Drake Nichols, an emergency room nurse at Kent General. "You're the patient's advocate as far as finding out anything they need and making sure they're not at risk for harm."

Not only are individual patients taking more medications; the number of medications available to treat patients continues has grown significantly as well.

"You used to have 10 different meds you gave throughout the day," Seiple said. "Now you have [hundreds of] medications and you have to know how every one works and you need to know what the side effects are."

There also are more patients. Vendla Esler, interim vice president of patient care services at Beebe, said her staff is seeing more patients with chronic lung disease, cancer, congestive heart failure and diabetes.

"They have to be very good at critical thinking," said Esler, who is also a registered nurse. "You have to know what's happening with them, you have to keep your eye on them."

A close eye on new laws

For hospitals to be accredited, the federal Joint Commission requires that they adequately manage patient flow and have safe staffing levels. The commission has found that reduced nursing staffs were a factor in almost one-fourth of the medical errors that resulted in deaths or serious injuries in hospitals.

But no national law exists that details what a proper patient-to-nurse ratio should be.

U.S. Rep. Janice Schakowsky, D-Ill., has sponsored a bill that would set registered nurse-to-patient staffing ratio requirements in hospitals, but the bill has not progressed.

The American Nurses Association says mandated ratios won't solve the problem. If a patient is significantly ill, for instance, a nurse may need more help than the ratio requires. But hospitals may not bolster their staffs because they would need to meet only the law's minimum requirements, said Cheryl Peterson, a senior policy analyst for the national nursing lobbying group.

"If you articulate what the ratio is in legislation, then that's all they'll do," she said. "That ratio may not be sufficient and may not meet the needs of the patients."

In 1999, then-California Gov. Gray Davis signed legislation that mandated specific ratios for nurses in various departments of the state's hospitals, the culmination of a lengthy lobbying battle between the state's hospital administrators and nurses. The number of newly licensed registered nurses in California grew from 3,200 a year prior to the law's passage to nearly 10,000 a year afterward.

In California, a ratio of one nurse to every four patients is required in emergency room care; a ratio of one nurse to two patients in the intensive care unit; and one to one in trauma.

Other states have been hesitant to adopt similar legislation because they're waiting to see how the law plays out in California, said Sean Clarke, a registered nurse and associate professor at both the Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto and the University of Pennsylvania School of Nursing.

Within five years, he said, data will be ready from California that can show whether an increase in nurses leads to better patient care. The data will take into account medical errors and overall patient satisfaction. If it turns out that the mandated ratios don't reduce medical problems, the law will be a wash, he said.

"What this boils down to is whether we believe hospitals will be safer if laws or regulations constrain managers in what they can and can't do," said Clarke, who has been studying the issue for 10 years.

Meanwhile, a study in the Health Affairs medical journal found that 6,700 patient deaths and 4 million days of hospital care could be avoided each year in the U.S. by hiring more registered nurses. The study also found that increasing nursing staffs actually would save hospitals money because they would paying less in the way of settlements for malpractice lawsuits.

'Nurses now are frazzled'

While nurses work in outpatient institutions, doctor's offices, nursing homes, private homes, day treatment centers, government agencies, schools and retirement communities, the demands on them generally are greatest in hospitals.

When too few are on a hospital floor, crucial tasks such as evaluating a patient's medications and preventing bedsores might not be performed. Sometimes, nursing duties fall on workers who are less skilled, said Peterson of the American Nurses Association.

Nursing student Brie Crabill has seen the stress on registered nurses during her clinicals, the hands-on portion of the nursing program where students are exposed to various health care environments and types of patients.

"Nurses now are frazzled, they're caring for six to eight patients and that doesn't sound like a lot, but these are six to eight patients who are on 10 to 15 medications each," she said. "You're constantly giving meds, constantly checking to see if patients aren't having adverse reactions and it gets hard."

"The hard part for a lot of nurses is that you are assessing and moving in a manner where whoever needs the most acute care is going to get that first and you have to prioritize your treatment plan to them," said Nichols of Kent General Hospital. "You have to make a lot of judgment calls and have a care plan based on each patient so the staff can't be burned out."

The median age of a Delaware nurse is 44, according to the Delaware Health Care Commission's most recent report. The U.S. Bureau of Labor Statistics reports that the nursing profession is aging and retiring at twice the rate of most occupations.

But merely filling in retirements with new nurses isn't the solution, said Esler, the interim vice president of patient care services at Beebe.

"Nursing isn't something you can do with excellence just stepping out of the gate," she said. "It takes years to really be an excellent nurse. The concern is whether there is going to be enough nurses and whether those nurses are going to have the skill set and experience."

A lot of nurses coming out of graduate school want to work at Christiana Hospital, Seiple said, but they burn out quickly.

"When new nurses go on a floor, they get a large volume of patients and they panic and they quit," said Seiple, head of the Delaware Nurses Association and also vice president of patient care services at Christiana Hospital. "It's a constant revolving door."

Some hospitals also are taking steps to address the shortage. Hospitals with nursing schools, like Beebe, are looking to expand. Most also offer sign-on bonuses. Some have gotten more creative, starting online auctions where nurses can bid on extra shifts and offering 9 a.m.-to-2 p.m shifts for nurses who are mothers so they can work while their kids are in school.

Bayhealth offers a six-month orientation program for new nurses, and four years ago launched an initiative to recruit enough nurses to address its expected turnover of about 10 percent. The health system recruits from almost 30 college and university nursing programs, up from seven nursing programs five years ago.

"A couple things are going to happen when you make the hiring of nurses a priority," said Marianne Foard, a registered nurse and manager of professional recruitment and retention at Bayhealth. "You will have improved patient outcomes and you will have a nursing work force that is satisfied. Nurses stay in the profession for two reasons: They have job satisfaction and they are engaged in their practice."

Some hospitals have reached out to retired nurses or those who are about to retire.

"As baby boomers start retiring, we're going to face a huge brain drain," Seiple said. "If there's any way we can get people close to their retirement to stay around and keep their hand in it, if we can do things that will maximize their abilities, that will help us. We have to get a little bit more creative."

Most agree that, to maintain higher nursing staff levels, the health-care industry needs to improve work conditions, among other things.

Esler said there's still time.

"I hope we do all the right things to overcome the shortage," she said. "We can do the right things to make it happen."

Contact Hiran Ratnayake at 324-2547 or hratnayake@delawareonline.com.

Delaware short of nurses who speak Spanish

Donna Reyes created one of her most valuable medical tools.

A registered nurse who works with expectant mothers, Reyes filled eight pages of a spiral notebook with handwritten questions in rudimentary Spanish so she could communicate with Spanish-speaking patients who had immigrated to Delaware.

¿Tiene dolor por las contracciones? Do you have pain due to contractions?

¿Tiene dolor? Do you have pain?

¿Dónde le duele? Where does it hurt?

"I would take it right in the room with me when I was talking to the patients," Reyes said of the notebook, which sits on her desk at Westside Family Healthcare. "I still have it here."

She rarely needs it now. Having worked with so many Hispanic patients in her four years at Westside, Reyes has mastered just enough Spanish to do her job.

Increasingly, patients at Delaware's federally-qualified health centers, which serve as safety nets for the indigent, hail from Central America, South America and the Caribbean. They labor as landscapers in Wilmington, poultry workers in Georgetown and mushroom farmers across the border in Kennett Square, Pa.

Delaware faces a general nursing shortage over the next decade, but it also faces a specific shortage: nurses who can communicate with the growing number of Spanish-speaking immigrants. The fear is, that with few Spanish-speaking health care workers, those who speak Spanish only, or little English, will be less likely to seek medical treatment.

"There is a specific shortage of bilingual, bicultural nurses," said Maria Matos, executive director of the Latin American Community Center. "Those who do not speak English well are less likely to see health care for a chronic disease."

Matos is on the Governor's Consortium on Hispanic Affairs, which commissioned a recent survey that found that 22.3 percent of Hispanics won't seek out a doctor or nurse for a checkup because they are not proficient in English. More than one in four Hispanic adults in the United States lacks a usual health care provider, according to the Pew Hispanic Center.

"Part of the reason is that they don't understand what's going on and they don't understand the health care profession," Matos said. "You're less likely to go back to a place where people don't understand you and where you came from."

Delaware saw the country's 19th highest rate of growth in its Hispanic population from 2000 to 2007, rising 51 percent to about 56,000, according to Pew Hispanic Center tabulations of U.S. Census data.

A report by the Delaware Health Care Commission on the First State's nursing shortage found that fewer than 1 percent of nurses were Hispanic.

Delaware should respond by training more nurses to be culturally competent, said Dr. Jane L. Delgado, a psychologist who heads the National Alliance for Hispanic Health.

"You also need to train the people that you already have there. It's like if you lived in a community and went from serving teenagers to serving an older population," she said. "You would have to change what you do."

Strangers to health system

The language barrier is just one of many problems. Challenges occur because many immigrants -- legal or not -- don't understand how the U.S. health care system works.

Many don't understand the concept of prescriptions. When their medicine runs out, some fail to return for refills. Since many are uninsured, they skip appointments if they can't pay.

Some wait until their illness becomes debilitating before seeking help. Some pregnant women, having given birth before without the guidance of a medical professional, wait until the third trimester before going for prenatal care. Some fear they'll be ridiculed for their home remedies and don't divulge them, running the risk of violent interactions with prescribed drugs.

Crucial to improving these patients' health and increasing their knowledge of health care is a favorable first visit.

"Nurses have that very unique role where they are closer to their patient than the doctors and other health professionals," said Delgado. "They are much more attuned to what the patients are dealing with."

When Reyes was a nursing student at the University of Delaware, she took a class on providing culturally competent care. After graduating with a bachelor's degree in nursing four years ago, she joined Westside Family Healthcare, the largest federally-qualified health center in Delaware, with three clinics in New Castle County. Fifty-one percent of the patients who go to Westside are uninsured and 39 percent are on Medicaid, the federal-state insurance program for the poor.

She started at the center's West Fourth Street location in Wilmington and now works at the Newark office, where about half the patient base is Hispanics who speak only Spanish.

Translations a problem

The proportion of Hispanic patients at Westside Family Healthcare is 64 percent. At La Red Health Center in Georgetown, it's just slightly lower -- about 60 percent -- and most of them speak Spanish only. The other two local organizations that run federally-qualified health centers -- Henrietta Johnson Medical Center and Delmarva Rural Ministries' Kent Community Health Center -- also treat immigrant patients, though not as many. Because questions about immigration status are not directly related to health, patients do not have to reveal whether they have illegally entered the United States.

When a translator isn't available at the centers, sometimes a patient's bilingual child is asked to translate. Misunderstandings can arise out of this situation, leading to medical errors, according to the National Center for Cultural Competence at Georgetown University.

La Red has four translators and several bilingual employees, said Barbara Richards, a registered nurse who helps expectant mothers. But it would be preferable if nurses could communicate with patients directly, she said.

"We need to decide whether they need to come in and see a doctor or go to the hospital or take a Tylenol," said Richards, who does not speak Spanish. "In order to do that you really need to be able to communicate with them rather than having someone else translate the entire visit."

Richards has memorized questions she needs to ask her patients in Spanish.

"I can get through most of my translation without assistance, but if there's anything new that they have to say, or if I have my doubts about what they're saying, I'll have to run and grab a translator," she said.

With many of those patients, she has to spend several minutes trying to gain their trust.

"No matter what country they're from, they tend to not want to give away all their private information when they first meet you," she said. "You have to take some time to warm up with them, and explain to them that whatever they tell us is confidential and will not be going outside the doors."

Six months pregnant

Many pregnant patients at La Red do not seek care until they are in their sixth month, too late for some tests on the fetus' health.

Often, the visits are complicated because patients do not want to admit they don't understand what is being said.

"You have to explain the importance of what they need to do and explain it multiple times," Reyes said. "I'll do a lot more pointing and use a lot more motions."

That means some visits that should last 30 minutes go on for an hour and a half.

Over the years, the Hispanic community near La Red has become more trusting of the center. But many are still reluctant to seek help because they fear that they won't be able to afford the cost or will risk exposure of their immigration status.

"I can't give you an exact percentage, but probably half the patients I see have something that should've been taken care of a long time ago," Richards said. "They are showing up at the door really sick."

Immigration issues can severely complicate care. A recent Hispanic patient of Reyes' was a mother who had diabetes and a sexually transmitted disease. Her boyfriend was arrested for physically abusing her and deported. The boyfriend had been paying for her medicine. She couldn't afford the medicine on her own and had to stop taking it.

"When you have to choose between food and other things that you need, you might have to make the decision where you won't go see the doctor," Richards said. "They'll ask if there's something they can do over the phone rather than having to come in and be seen."

Many will visit botanicas, which sell herbal remedies and provide access to curanderos, or folk healers. Richards asks Hispanic patients to list medicines and herbs they are using because of potential interactions.

Reflecting the change in the patient population, nursing students at Wilmington University can obtain a Hispanic Cultural Certificate. The program consists of 18 undergraduate credits, including three Spanish-language classes, and students are required to practice in community health settings that treat Hispanic patients.

"We believe it's important, because in order to treat someone appropriately, it is important that some of the health beliefs and values that other cultures may have are understood," said Sheila M. Sharbaugh, coordinator of the bachelor of science in nursing program. "Different cultures have different beliefs with health and with illness."

Jane Boyd, an instructor at Wilmington University's Georgetown campus, teaches "Cultural Diversity in Health and Illness." The course's lessons range from immigrants' cultural heritage to their sleep patterns to the type of work they do. Many patients who work in the poultry industry come to the emergency room with trauma-related injuries. Many of their children play soccer, making them susceptible to physical injury or heat exhaustion.

"How you seek care and how you respond to a provider is also based on your background," Boyd said. "Some of the things we do are just like what they do. ... But to be culturally competent, you need to understand your world views and the views of the patient."

Prenatal visit

On a recent day, Reyes met with 27-year-old Griselda, a Mexican immigrant who has had two children and one miscarriage. She came because she was pregnant again.

Griselda works in construction eight hours a day and speaks little English.

Reyes asked one question after another in Spanish. Each question was slow, and she hesitated several times, making sure that she was as clear as possible.

Reyes ran her hand across Griselda's midsection and asked about her condition.

Reyes spoke to Griselda about nutritious diets and the dangers to a fetus from periodontal disease. Care in the United States is much different than in Mexico, Griselda said.

"If you have money you get seen more often there," she said through a translator. "But here they treat you and it's affordable. I've learned what [healthy foods] to eat while I'm pregnant. I tell my friends about Westside."

At the end of the appointment, Reyes ran a monitor across the her abdomen so she could hear her baby's heartbeat. It was 150 beats per minute, ideal for a fetus of 25 weeks.

"Muy bien," Reyes said.

These stories on the nursing shortage were reported with the assistance of the USC Annenberg/California Endowment Health Journalism Fellowships, administered by the USC Annenberg School for Communication. The News Journal was selected by the program in 2008 to report on the nursing shortage, with a particular focus on the impact on Hispanic communities.

Contact Hiran Ratnayake at 324-2547 or hratnayake@delawareonline.com.

Practice trains nurses to work with Spanish-speaking patients

St. Francis Center of Hope was opened in August 1996 to serve low-income Spanish-speaking patients. The family practice, run by St. Francis Hospital, is located in Red Mill Square in Newark, neighboring Ruby's Mexican Store.

As the Hispanic population has swelled in Delaware, so has the patient base at Center of Hope. It is an ideal learning ground for nursing students interested in working with the Hispanic population.

"What the students learn is how to be minority," said Sister Elise Betz, one of the two registered nurses on site. You see things in the center you won't see in other clinics, Betz said. Family members often accompany patients into the rooms. Some of the patients bring ethnic foods to give as tokens of appreciation for care.

"When you see all those people in there, nurses could be thinking it's a party but that's not what it is," Betz said. "If they don't speak English, they could come in here and not have a clue what the doctor is talking about and then they can get scared."

With the help of a nursing student, the Center of Hope developed a booklet of various medications that are recommended for the common illnesses of pregnant women and children. The booklet contains pictures of the packages of the medications so non-English-speaking patients can visually identify which ones they need.

"When the patient goes into Happy Harry's to buy a medicine for their kids and there are 4,000 different Tylenols, they have a tendency not to know what to give them," Betz said. "But with the booklet, they can look for the picture."

Dr. Jane L. Delgado of the National Alliance for Hispanic Health said nursing students who are experienced in treating a variety of patients will be more valuable as demographics shift.

"You can save the system money when nurses are trained," Delgado said. "You won't practice bad medicine but will be able to treat the problem."

Contact Hiran Ratnayake at 324-2547 or hratnayake@delawareonline.com.

Would-be nurses can't find enough classrooms

The nursing shortage isn't caused by a lack of people who want to become nurses.

Only a couple years ago, Delaware Technical & Community College – which has separate nursing schools at its campuses in Dover, Georgetown and Stanton – had almost 800 people waiting to get into its nursing program. The program has since expanded, but there is still a waiting list of nearly 400.

That means plenty of qualified prospective students, such as Brie Crabill, must wait. The 31-year-old mother of three started nursing school at Delaware Tech in January 2005. A transfer student, she "was under the illusion that I'd be done in two years."

But, after taking the pre-admission exam, she was unable to get into the hospital clinicals until this spring.

Crabill still has two more semesters of clinicals before she'll be able to take her nursing exam. She doesn't expect to become a nurse until January 2010. At times during her wait to get into clinicals, she considered another profession, even though she's wanted to become a nurse since she was 18.

"I have three kids and balancing my schedule with their schedule is hard," she said. "The wait is a deterrent to people who are on the fence about whether they should go into nursing."

Another hurdle is access to science classes. A limited amount of lab space must accommodate nursing students and students in 17 other health fields. Delaware Tech expects the number of students unable to access the science courses will more than double in the next five years.

"The major bottleneck used to be the clinical sites," said Jo Ann Baker, a family nurse practitioner and chair of the nursing department at the Delaware Tech campus in Dover. "But the second bottleneck is just trying to get them into the science classes."

Delaware Tech is lobbying state government to build three new health and science buildings – at a $100 million price tag.

Becky Boney, of Townsend, said to get into the classes she needs, she has to get up at 4 a.m. to wait in line at the beginning of the semester.

"It's frustrating because you're excited about getting in," said Boney, a licensed practical nurse working to become a registered nurse. "But they just don't have the capacity." Often at the Stanton campus, LPNs training to be RNs literally spill out of classrooms. The school has had to get creative in its use of existing space.

"Sometimes we'll take the simulation mannequins and move them on stretchers into the corridor," said Kathy Janvier, a registered nurse and chair of the nursing department at the Stanton campus. "We have installed outlets right out in the halls so space can be used."

Contact Hiran Ratnayake at 324-2547 or hratnayake@delawareonline.com.

© 2008 News Journal (Wilmington, Del.) (used by permission)