Dr. Fowler is a clinical nurse researcher at Morristown Memorial Hospital in Morristown, NJ, and a former president of a national specialty nursing organization.
By the year 2020, it is projected that there will be a national shortage of about one million nurses. But we don't have to look that far into the future to know that the crisis is already here.
According to a 2007 report by the American Hospital Association, hospitals need approximately 116,000 registered nurses to fill present vacant positions, and the Council on Physician and Nurse Supply estimates that 30,000 additional nurses will have to graduate from nursing programs annually to meet the nation's health care demands. Additionally, a 2006 survey from the Nursing Management Aging Workforce indicates that many nurses will retire between 2011 and 2020, making the shortage even more dire.
Regardless of your neurology specialty or practice setting, you are probably already affected by the nursing shortage — or you will be in the near future.
EFFECT ON BEDSIDE CARE
In hospitals, fewer nurses mean higher patient-to-nurse ratios. Data from a 2003 JAMA study showed that increasing nurse staffing in hospitals, not decreasing it, is associated with better outcomes: mortality is decreased, there is less failure to rescue, and length of stay decreases. This is even more evident with an increased number of baccalaureate prepared nurses.
As nurses care for more patients, they are challenged to provide best practices for more patients, often with more severely ill patients. They struggle to pay close attention to detail such as changes in mental status and timely delivery of medications, for example those used by patients with Parkinson disease.
Neurologists may find that nursing assessments are not “catching” minute changes in patients and interventions are not being delivered as prescribed. As the nursing workforce ages and seasoned nurses retire, fewer experts are available at the bedside to mentor those less experienced in nursing process and clinical decision-making. As a result, neurologists will have to “step up to the plate” to teach and provide more guidance to nurses providing bedside care.
Neurologists must also be aware that aspiring nurses are not entering bachelor degree programs as often as they are opting for diploma or associate degree programs. Fewer students are enrolled in generic and advanced nursing programs, and fewer advanced practice nurses are being trained as nurse practitioners and clinical nurse specialists.
Nurse practitioners (NPs) and clinical nurse specialists — expert clinicians in specific areas of nursing practice — can complement the care provided by neurologists. NPs provide clinical care, disease prevention and health education services, and counseling; they also order diagnostic tests, diagnose, and facilitate treatment, including prescribing medications.
The National Association of Clinical Nurse Specialists reports that research has shown that clinical nurse specialists can have a positive impact on reducing hospital costs and length of stay, less frequent visits to the emergency room by patients, improved pain management, increased patient satisfaction, and decreased medical complications of hospitalized patients.
This increasing shortage in nurses at all levels of practice — physician offices, specialty clinics, and alternative care settings — may make it difficult for neurologists to recruit nurses to provide care for patients in the hospital and also for outpatients. This will increase the workload for neurologists and limit services.
Having fewer baccalaureate-prepared nurses at the bedside threatens quality care and prevention of complications. Neurologists may have to be extra vigilant when conducting their rounds in hospitals.
There has been a proliferation of stroke coordinators, for example, since the FDA approved tissue plasminogen activator and the certification of primary stroke centers. The nursing shortage may have a negative impact on the growth in these professionals and the provision of acute stroke services in communities and university hospitals.
As nurses in hospitals work harder with fewer peers and less support, they may leave bedside practice and seek opportunities to direct patient care. This decision will also be influenced by salary demands and quality of life for nurses.
Managerial support has been found to be critical to bedside nurse satisfaction. Neurologists need to establish collaborative relationships with nurse managers and provide support that can be filtered down to other nurses providing patient care. An atmosphere of respect is important to all nurses, regardless of position or title. By acknowledging and supporting nursing's unique contributions to patient care, neurologists can have a positive impact on nurse satisfaction and possibly, retention.
• Aiken LH, Clarke SP, Silber JH, et al. Educational levels of hospital nurses and surgical patient outcomes. JAMA
• Buerhaus P, Donelan K, Norman L, et al. Physicians assess the effects of the nursing shortage on quality of care and hospital processes. 2005. Academy Health Meeting. Abstract no. 4166.