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After the Match: The Arms Race in ED Nursing

Cook, Thomas MD

doi: 10.1097/01.EEM.0000471527.68086.a2
After the Match

Dr. Cookis the program director of the emergency medicine residency at Palmetto Health Richland in Columbia, SC. He is also the founder of 3rd Rock Ultrasound (http://emergencyultrasound.com). Friend him atwww.facebook.com/3rdRockUltrasound, follow him @3rdRockUS, and read his past columns athttp://bit.ly/CookCollection.

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It's a rare day that the increasing physician shortage isn't in the media. New medical schools have been created, and established ones have increased class size. But another shortage is having a dramatic effect on your current and future ability to practice.

A couple of years ago, my wife had a procedure in the outpatient surgery center where I work. Hospitals will do anything to convince competent, insured patients to come in for a few hours, and then charge them $15,000 to $20,000. These patients always go home, complete their post-operative care, successfully convalesce, and pay their bill. I was with her the entire time, and it was a great experience. The facility was beautiful and had great customer service. The nursing staff was kind, skilled, and professional. All of them made a point of telling us they had more than 20 years of experience, and it showed.

This is in stark contrast to the patient experience in our ED. One nurse splits time between three to four patients, and patients are relegated to hallway beds when the ED gets overwhelmed. This forces us to move nurses from our nonurgent beds to support the care of more critically ill patients. ED beds get closed, patients wait longer, frustration builds, and Press Ganey scores drop.

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Best Talent in the ED

We have a cadre of incredible nurses who have been with us forever. There is always, however, a large group of new nursing school graduates who go through six months of orientation and then work with us until they find something better. My hospital is certainly not the only one in this situation, and teaching hospitals operating on relatively thin profit margins cannot afford to get into a financial arms race with other for-profit hospitals that will raise wages to pull in nursing talent.

It is not uncommon for us to see a great nurse give notice that he is leaving for another hospital in town for $5 more per hour. This might not sound like much, but it is another $10,000 for a nurse working 2,000 hours per year. The national average salary for nurses is $66,000, and $10,000 is a 15 percent increase in pay.

The irony is that the sickest and most difficult patients come through the emergency department, which has become the entry point for many nursing graduates who do not qualify for other jobs because of a lack of experience. Quality is the buzzword in health care, so putting your best talent in front of your most at-risk patients would make sense. How did we get to this point?

It's basically a case of supply and demand. Nursing is one of the top occupations for job growth, but it does not meet demand because of a shortage of nursing school faculty, a large segment of the nursing workforce nearing retirement age, an increasing demand for chronic care of the elderly, and nurses pursuing training to become nurse practitioners, anesthetists, and administrators. The expectation that smart college graduates will help people with bedpans while being verbally assaulted for decades at median incomes is unrealistic.

Add to this the travel nurse phenomenon ravaging hospital budgets everywhere. Most travel nurses make roughly twice the income plus a stipend for living expenses. When the hospital runs out of local resources, it must pay through the nose and destroy the morale of its own staff to bring in people with no commitment to the organization and, at times, a poor work ethic.

It is imperative to our clinical quality of life to have an adequate number of qualified nurses. This will not be easy. But if we are smart, we will make it a priority to become advocates.

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