Sutton's Law and 90,000 Missed Opportunities to Address the Nursing Shortage

My MBA class on strategic management at the University of Alabama at Birmingham had two traveling nurses among the students this past semester. One lives in Atlanta, Georgia, and commutes to Birmingham, Alabama, for work. The other lives in Birmingham and commutes to Atlanta. They literally pass one another on the freeway as they traverse their 2-hour commutes to and fro. Although I know the answer, the question nevertheless begs to be asked: Why travel so far when you can work full-time in the cities where you live? Their response channels the ghost of bank robber Willie Sutton: Because that's where the money is. Traveling nurses get paid nearly double their full-time counterparts.

The infamous rationale for robbing banks has become known as Sutton's Law and is primarily taught in medical schools. In the clinical setting, the law is intended to remind physicians to consider the most obvious diagnosis first and order the cheapest test to confirm (or rule out) an illness. As we like to practice what we preach, let's apply Sutton's Law to the nursing shortage and the rise in the use of traveling nurses. To do so, there are two questions to ask. First, what are the most likely and obvious causes of the nursing shortage? Second, what are the least expensive solutions to the problem?

With respect to the causes of the nursing shortage, the simplest answer is one of supply and demand. The U.S. educational system is not supplying enough nurses to meet the healthcare sector's needs. One might assume that there are not enough people interested in the nursing profession to meet the demand, but that is not the case. In fact, the ^{American Association of Colleges of Nursing (2022)} found that more than 90,000 qualified applications (not applicants) were turned away from nursing schools. The schools indicated that there were three main constraints to accepting more students: (1) the limited number of clinical rotation sites restricts class sizes; (2) a lack of faculty to teach larger cohorts; and (3) insufficient scholarships or financial aid for applicants. Each cause suggests at least one solution.

The biggest challenge to the nursing supply is the lack of clinical rotation slots in health systems. Although simulation tools can relieve some of the pressure, there is simply no substitute for working on the floor and at the bedside. By its very nature, this problem implies that it is the health systems and their leaders that need to make a concerted effort to increase clinical rotation availability. In our March/April interview, President and CEO John M. Haupert, FACHE, described how Grady Health System doubled the number of nursing rotation opportunities in partnership with local nursing schools. If more health systems made a similar effort, the nursing shortage would end much sooner.

The second issue revolves around the number of nursing educators. As educational expectations have risen, so have the levels of education required by most nursing schools for faculty. The federal government and states are making a concerted effort to open the pipeline of doctoral-prepared nursing faculty, but that is a long-term solution. Nursing education must find some near-term alternatives.

A more immediate opportunity for increasing the nursing workforce, and one well within health system administrators' control, is a return to the past. For generations, nurses were educated within the hospital itself under apprenticeship models to create “diploma” nurses. Although the current preference is for baccalaureate-educated nurses, the short-term solution of having paid apprentice programs would address some of the shortage. Moreover, paid apprenticeship models would also ameliorate the financial headwinds that many applicants to nursing schools face.

There is no single solution to fix the nursing workforce supply side. Multiple solutions need to be employed, including the opening of visas to internationally educated nurses. The other way to reduce the nursing shortage is to work on the demand side of the equation. Nursing voluntary turnover rates (VTOs) are simply too high. If a small fraction of the premium that goes to traveling nurses was applied to improving the working conditions of currently employed nurses, the VTOs would likely decline precipitously. Although Sutton's Law might suggest that this is an obvious solution, far too few health systems are doing it.

IN THIS ISSUE

Baljeet S. Sangha, FACHE, COO of the San Francisco Health Network, deputy director of the San Francisco Department of Health, and 2023 recipient of the American College of Healthcare Executives Robert S. Hudgens Memorial Award for Young Healthcare Executive, is this month's featured interview. Mr. Sangha describes his system's approach to meeting the immediate needs of marginalized individuals. It is not based on building new clinics but rather on an infrastructure of trust.

Our yearlong series of guest columns on change management continues with an inside look at the Veterans Health Administration's (VHA's) current quality improvement campaign. Gerard R. Cox, assistant undersecretary for health, quality, and patient safety, and Leigh Starr, director for high-reliability enterprise support, describe the nation's largest integrated healthcare system's journey to high reliability. The VHA has been at the forefront of this cultural movement, and the lessons its leaders are learning along the way are valuable to all health systems. One of the pillars for success relates to leadership, which is a good segue to the empirical research articles in this issue of the Journal of Healthcare Management.

For their comprehensive study of the span-of-control phenomenon in nursing, Asiah Ruffin, RN; Maria R. Shirey, PhD, RN, NEA-BC, ANEF, FACHE, FNAP, FAAN; Tracey Dick, PhD, RN, CNE, COI; Pariya L. Fazeli, PhD; and Patricia A. Patrician, PhD, RN, FAAN, reviewed 185 prior research articles and identified 22 that quantifiably analyzed the topic. Their findings suggest that many nurse managers have more people reporting to them than is optimal. Spans of control that are too broad create unproductive stress and contribute to the burnout prevalent in the workforce today.

Shea Polancich, PhD, RN; Rebecca Miltner, PhD, RN; Aoyjai Montgomery, PhD; Tracey Dick, PhD, RN, CNS, COI; Terri Poe, DNP, RN; Daran Brown; and Patricia A. Patrician, PhD, RN, FAAN, look at how traveling nurses versus regular staffing affect key clinical outcomes. Suffice it to say, they identify yet another reason to get the nursing shortage under control.

An often-neglected group in health services research is adolescents. Emma McCord; Joseph H. Ballard; Carol A. Mills, RN; Elhaam Bandali; Teresa M. Bell, PhD; and Olena Mazurenko, MD, PhD, conducted a qualitative study of patient satisfaction and outcomes in this demographic. Their findings indicate that even younger patients benefit from empowerment in their plan of care.

Kariba Tucker, DHA, LPC, NCC; Dimitrios Zikos, PhD; and Dan J. Vick, MD, DHA, CPE, take a big-data approach to analyze how discharge disposition affects readmissions among patients with a psychotic disorder diagnosis. They find that more engaged discharge approaches such as the use of home healthcare can reduce readmissions. However, as with many other services, the nursing shortage has greatly limited the amount of home health available in some communities.

As the direct effects of the COVID-19 pandemic recede, we are left to assess its long-term structural impact on health systems and their workforces. No group was more adversely impacted by the epidemic than the nursing profession. A concerted effort to improve their collective working conditions and increase the number of people entering the profession is needed.

Eric W. Ford, PhD
Editor