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After the Match

After the Match

‘Indentured Servitude’ Could Solve ED Nurse Shortage

Cook, Thomas MD

Author Information
doi: 10.1097/01.EEM.0000512767.15753.6a
    nursing shortage
    nursing shortage:
    nursing shortage

    This picture was taken by a colleague in a New York subway station. The implications are all too familiar for emergency health care providers. We do not have enough nurses to go around, and emergency nurses are leveraging this shortage to bolster their income by working as “travelers.” It's nice to see great nurses receive better compensation, but the explosion of nurses working as locum tenens creates significant morale issues within an ED. (“The Arms Race in ED Nursing,” EMN 2016;37[9]:21.)

    Like many other emergency departments, mine has issues with nurse staffing, and it's tough going to work without knowing how many nurses will be on duty. I propose using a strategy that sounds pretty drastic — indentured servitude, the strategy used by the U.S. military.

    The military has for decades offered scholarships to medical students in return for service after residency. Given the skyrocketing price of medical school, many future physicians see this as an attractive alternative to overwhelming debt. It certainly appealed to me in the 1980s when I had no way to pay for medical school.

    But how does this strategy affect the supply of nurses? We must recognize that this is a problem that will not be fixed in the near future. Even if we had a lot of young adults interested in nursing careers, there are just not enough nursing schools to meet the demand. This, in turn, forces hospitals to pay a lot of money to travelers to keep their EDs running, and this can add up to millions of dollars each year at larger hospitals.

    Changing the Game

    In light of this, hospitals with chronic nursing shortfalls need to convince nurses to stay at their institutions for the bulk of their careers, and they need incentives to achieve this. Many large medical centers (including mine) already have them to attract nursing school graduates. This is a mixed bag of enticements like signing bonuses or the promise to pay off a percentage of student loans. New nurses, in return, commit to staying on for one to two years.

    One-to-two year commitments typically fail to embed average nursing graduates in their early 20s into the local community or create significant loyalty to the institution, however. What these hospitals really need are programs to hold on to these nurses for five to six years, a significant period of time during which young adults tend to marry, have kids, develop strong friendships, and buy homes. This creates a “stickiness” that makes it much harder for them to leave.

    Hospitals need to change the game. They should utilize the military strategy to recruit nurses and pay upfront for their nursing education, requiring multi-year commitments to stay put in return after the training is completed. They should also focus on recruiting older students who have completed an undergraduate degree but are having trouble finding relevant work, particularly those with burdensome student loan debt. They could offer not only to pay for their nursing education but also debt relief in exchange for a longer post-graduation commitment.

    Hospitals should build their own nursing schools to facilitate this. Why are they waiting for universities to do everything? They already have access to clinical training. All that is left is an adequate number of classrooms, online libraries, instructors, and strategic marketing. This is expensive, but hospitals in the end will have hard assets that can be used again and again. It is much cheaper than paying exorbitant wages to traveling nurses with little to show for it at the end of the day.

    Consider the 25-year-old college graduate with $30,000 of student loan debt who is not satisfied with his current employment and is ready for a change. Your hospital can offer to cover the student loan and provide free tuition for a nursing degree at your own “homegrown” nursing school, and the student would think it is reasonable to commit to working in that hospital at full pay for five years after graduation.

    It would be worth it even if every person of a 100-member nursing school class got the same deal. Five years after the initial class has graduated, there would be not only 500 “homegrown” nurses at your hospital, but also 100 new nurses each year going forward. This provides the incredible luxury of aggressively pursuing the great nurses to stay while thanking the less skilled ones for their contribution when they leave. Think about it: Which hospital can do this now?

    Unfortunately, hospital leaders are often loath to make long-term bets on clinical personnel. There is a huge startup cost, lots of work, administrative hassles, and the potential for poor return on investment. And the administrator often has already left the position and does not share in the achievement by the time the payoff is realized. Just as HCA is building residency programs to fill their hospitals with physicians in the future, however, hospitals must recognize that nurse shortages are not going away any time soon and take action now to create the next generation.

    The MD Shortage

    Read Dr. Cook's column about how corporate America is aggressively creating residency programs to train and retain graduates at

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