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Best Practices

Based on a comprehensive review of the evidence, the following improvements in nurse working conditions are essential to solve the nursing shortage:

  • Improve pay and benefits.
  • Increase staffing levels, and involve nurses as equal partners in determining appropriate staffing levels.
  • Prohibit the practice of mandatory overtime and maximize scheduling options.
  • Provide nurses a meaningful and effective voice in shaping workplace policies.
  • Increase access to internal and external education.
  • Support efforts of nurses to represent themselves through collective bargaining.

Compensation

Real wages for the nation's RNs stagnated over the course of the past decade, with inflation-adjusted earnings in 2000 virtually identical to where they were in 1990.11 One recent survey reported that only 36 percent of nurses feel they are being paid a fair wage.12 The most important proposal for compensation is also the simplest: pay more.

Staffing

The 1990s saw widespread nurse layoffs in the hospital industry. Fully 64 percent of nurses report that they have less time available for direct patient care than they did just two years ago.13 The U.S. General Accounting Office reports, "When adjusted to reflect the rise in acuity levels, the number of hospital employees on staff for each patient discharged, including nurses, declined by more than 13 percent between 1990 and 1999."14

Nurses report making huge personal sacrifices in an effort to provide decent care to their patients. Despite these efforts and sacrifices, nurses report that because of reduced staffing, the quality of care has declined. According to one survey, over the past two years15

  • 78 percent of nurses skipped meals and breaks to care for patients.
  • 58 percent worked voluntary overtime.
  • 33 percent worked involuntary overtime.
  • 58 percent were unable to attend in-service continuing education programs due to increased work.
  • 51 percent experienced stress-related illness.
  • 58 percent cite delays in providing basic patient care, such as feeding and bathing.
  • 50 percent believe patients were discharged without adequate preparation.
  • 38 percent cite treatment errors such as patients put on the wrong diet or delays in laboratory testing.
  • 37 percent cite failures of staff to recognize significant patient symptoms.
  • 36 percent cite increased medication errors.

Mandatory staffing ratios — whether established by law or through collective bargaining — are by far the most promising means for solving the staffing problem. Indeed, management in hospitals that have adopted such ratios has come to appreciate them. Cape Cod Hospital in Massachusetts, which signed a collective bargaining agreement in 1997 mandating a 1:5 staffing ratio for medical/surgical units (with a skill mix of 85 percent RNs), initially resisted the proposal but now hails it as a cornerstone of recruitment strategies.16

In 1999, California adopted the first law in the country mandating specific staffing ratios.17 Where such legislation is politically feasible, it will likely do more to solve the shortage than negotiating staffing language at individual hospitals. The latter may simply result in luring nurses from one hospital to another; the former will help draw currently non-working RNs back into the health care industry.

 

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