I remember when I started nursing school about a decade ago, that there was a near militant attitude describing the nursing shortage. School administrators, politicians, and journalists hopped on this easy bandwagon and talking point. Research and polls of dubious quality rode the tidal wave of popular opinion. Unsurprisingly, their genesis in an echo chamber yielded predictably confirmatory responses. As graduation time was fast approaching, the class began to job hunt … and there was nothing. The few jobs in the region asked for the golden “one year of experience” and yet nobody was prepared to give it. Worse yet, this experience was required to be in that particular setting. It was a classic catch-22. Many graduates languished with unemployment/underemployment, fighting for exploitative part-time nursing homework.
Ten years later, there does seem to be a stronger recruiting effort for nurses. It’s a surreal feeling now, having been borderline unemployable once upon a time and now seeing actual signing bonuses. So did the talking heads accurately predict a nursing shortage then? In my (admittedly anecdotal context) opinion, they didn’t. The least scrupulous polled various staff and physicians in the trenches — which might seem intuitive for determining what’s needed and what isn’t but ignores the fact that the grunts don’t make the hiring decisions. Others failed to recognize that organizations wanted veteran nurses for easy plug and play. In an era of accelerated outsourcing and general job loss, there was a lot of money to be made selling career training seats. The rosier the employment prospects, the better.
Nursing homes had been steadily growing in this time period, and it seemed a cottage industry sprung up for skeleton crew facilities. Horror stories abounded of absurd patient-to-nurse ratios; the most egregious I had heard was 100:1. It would be semi-joked about that by the end of your morning medication administration list, patients at the beginning would have died before you had the time to cycle back. I don’t have direct experience to confirm these tales, but the various nursing home scandals through the years seem to suggest at least a shred of truth exists. Today it appears that nursing homes too are struggling to recruit. This is much less surprising considering the low pay and constant squeeze for making do with less. Ironically, residents with dementia do better with a consistent environment and familiar faces, which a revolving door of staff handily foils.
This thrived in the shadow of hospitals largely shunning new graduates. As seen in history, businesses are thrilled at having an oversupply of cheap, disposable labor. But the hospital response was not illogical. Few facilities want to bear the cost and diminished efficiency of bringing new graduates up to speed. Time is money and especially in the most desirable places to live, why shouldn’t employers pick the path of least resistance? They are, like those nursing homes, in the enviable position of having an oversupply of labor with which they can be highly selective. This left community hospitals to pick up the slack.
In the modern world, it isn’t unusual now for people to move around the country throughout the course of their career. Big city dreaming has always captured the imagination but has gradually become idolized. Couple that with a high concentration of knowledge-based labor — the remainder of the job market after the gutting of manufacturing — and there’s every practical reason to go to the city. But those city hospitals demand experience. Where is the new graduate to get that golden one year? Community hospitals. I suspect that this has been a dilemma for far more than ten years. It is logical that community hospitals would not want to bear the costs of getting new graduates going, only to lose them as they start becoming proficient at their work. Many small organizations live and die on long-term anchoring staff.
Ten years ago, the answer was to recruit experienced staff, who don’t need the golden year anymore. They would plug in seamlessly, presumably be further along in having a family or other obligation that would make them less flighty, and overall cost far less while providing more. But ultimately this was a shortsighted strategy because it choked off the supply of new graduates becoming experienced and drew from a pool of nurses that was only so deep. Unfilled staffing needs led to the traveling or agency nurse becoming a necessity but at great cost. And when experienced nurses realize that the temps they’re working alongside are being paid more with less overall responsibility to the organization? The growth of agency should come as no surprise, and thus the pool of reliable, experienced nurses becomes even shallower.
This all brings us to today. Smaller hospitals find it increasingly difficult to fill in the schedule gaps. New graduates do their time at desperate facilities, moving onto bigger and better things once their year is up. Experienced nurses get older, sicker or just plain fed up with being paid less than the temp next to them while being expected to be available to take shifts or go home unpaid to save money. Enter the nurse practitioner education machine. For (over) the price of a bachelor’s and a master’s your experience in the trenches can be translated to a doctor-lite. For (over) the price of a DNP, you can try to call yourself doctor legitimately. Combining the artifice of career advancement with a way out of being treated like livestock, who could say no?
The coming crisis is not a shortage of nurses, but rather a lack of nurses willing to give in the face of diminishing reciprocity. To be in the position of trying to make things work is an unenviable one. Hard numbers on balance sheets for ailing community hospitals don’t lie, and many services don’t directly bring in money. As health care reimbursement continues to be razed, hospitals will have no choice but to cut, cut, cut to slow their descent into oblivion. It brings to mind one famous quote: “It became necessary to destroy the town to save it.”
Way Chiang is a resident physician.
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