Making the Difference in Patient Care

March-April 2003


The Winner of CHA's "Call for Innovative Ideas" Contest Discusses the Nurse Shortage

When those on the front line of the nurse staffing shortage—the nurses themselves—talk about the causes and solutions of the shortage, they often focus on several concepts that are key to the Catholic health care tradition: respect, recognition, support, and collaboration.

Many nurses say the health care marketplace's current focus on short-term solutions to the staffing crunch takes attention away from some core long-term concerns that must be addressed.

"As I talk to other nurses, I find the ultimate dissatisfiers have to do with them not feeling good about themselves or what they do," explained Elaine Hlopick, RN, MSN, who is nurse manager for the medical-surgical, oncology, and dialysis units at Saint Vincent Health Center, Erie, PA. "Incentives that improve salaries and make 'off shifts' and weekend coverage more attractive are only short-term satisfiers," she said. "The long-term solution lies in making nurses feel respected, recognized, and valued."

In April 2002, Hlopick won CHA's "Call for Innovative Ideas," a contest in which registered nurses (RNs) at Catholic hospitals submitted their ideas for addressing the workforce shortage issue in their field. One of nearly 350 entries, Hlopick's proposal called for the creation of a nurse advocacy office at CHA to promote the profession.

Hlopick said she developed the idea as a foundation for addressing what she sees as some of the longstanding root causes of the staff shortage. A long-term solution will require restoring some of the values that—from nurses' perspectives—have eroded over the years, she said.

A Changing Work Environment
When Hlopick entered the nursing field in the late 1970s, the nurse population and the working environment were much different than they are today.

Because of the comparatively limited career choices then available to women, nursing had a large pool of job candidates from which to choose. However, as career opportunities have opened up for both genders, fewer women have chosen the nursing field. Those who entered nursing 20 or 30 years ago and stayed are now nearing retirement age. In fact, a March 2000 study by the U.S. Health Resources and Services Administration found that the average age of nurses has increased dramatically over the past two decades.1 In 2000 it was 47 years. The same study found that growth in the population of practicing nurses has slowed in recent years.

Also, the population of patients has increased, and its needs have changed. The senior population is growing, and its health care needs are increasing, yet government reimbursement for the services that elders receive is not keeping pace. Hlopick said these seemingly "high level" factors have a pronounced impact on the day-to-day activity of frontline caregivers.

"Changes in the external environment have challenged nurses' ability to give the type of care they are committed to providing," she explained. "Patients are sicker, reimbursements are lower, and hospitals—and nurses—are continually being challenged to do more with less."

The changing demographics and shifting economy have, in Hlopick's opinion, led to uncertainty about nurses' role and value. "Nursing-care hours constitute a variable cost," she explained. "During times of plenty, it was easier to keep more nurses on staff; during times of tighter reimbursement, their role was diminished, and nurses became a disposable commodity.

"The result was some confusion over their value."

Hlopick said she—like many other nurses—recognizes that hospital administrators are faced with complicated decisions during a challenging time. And, she said, she believes hospitals are interested in addressing nurses' concerns.

"Hospitals do value nurses and recognize the contribution they make to patient outcomes," she said. "Yet they are faced with meeting the patient care challenge within the constraints of the reimbursement- and regulation-ridden environment—and it's a tough challenge.

"It's challenging to staff a unit where the census changes not just from day to day or week to week, but from hour to hour," she added.

Short-Term Fixes
Most health care providers are well aware of the nursing workforce shortages and are implementing programs to address the issue. In fact, in the fall of 200l the First Consulting Group, Long Beach, CA, reported that 82 percent of the hospitals it had surveyed said they were experiencing more difficulty recruiting RNs now than in the past.2

To meet their workforce demands, facilities are implementing a variety of incentive programs, including tuition reimbursement, new training offerings, flexible work hours, on-site child care, overtime incentives, and others. These efforts are much appreciated and much needed, Hlopick said, but they may not be a permanent solution.

"Hospitals everywhere have put in place measures to attract and retain nurses for the short run," she said. "They have implemented overtime incentives and recruitment and referral bonuses; they have developed new policies for training and orientation; they have revamped staffing patterns and schedules; and they have enhanced benefits and salaries.

"These efforts are having an impact on short-term issues," Hlopick continued. "But the long-term issues are less understood, and the nursing profession is just beginning to research causes and solutions."

A More Permanent Solution
To address the issues underlying the nursing shortage, Hlopick said, nurses, hospital administrators, and others must look beyond the "surface concerns." These constituencies must ask themselves how the changes that have occurred in the health care environment have altered the role of the nurse, Hlopick said. They must then ask what it is about this "new role" that is failing to meet the needs of nurses and potential recruits.

The answers to these questions, Hlopick said, will lead to a deeper understanding of the staff shortage and to more comprehensive reforms. In seeking to determine why the nursing profession is failing to recruit the same number of new nurses it once did, she said, it is helpful to look at why certain individuals are attracted to the career in the first place.

Hlopick's perspective is telling. Nursing is a "good fit" for her, she said, "because I enjoy a people-oriented job, and nursing provides me with the opportunity to interact with people on a daily basis. My greatest satisfaction still comes from doing something special that makes a difference in the day of a patient or family member—earning that extra smile or thank you."

The drive to help others is central to most nurses' attraction to the profession, Hlopick said. A failure to recognize this important factor can limit hospitals' ability to effectively address the nurse shortage.

"There seems to be a sense out there that 'anyone can be a nurse' and that nursing is the answer to growing unemployment rates: 'Just send everyone to nursing school; solve the nursing shortage and unemployment problem in one swoop,'" Hlopick said. "This stems from a lack of understanding of what it is that nurses actually do and [of] the education, skills, and training that they require. I think that this is the biggest obstacle we have to overcome."

Successful solutions to the nursing shortage will be based on the premise that "nurses are highly trained, educated individuals with astute critical thinking skills," she said. "They don't just make a contribution to patient care; they make the difference in the outcome of patient care."

A long-term answer to the nursing profession's recruitment and retention problems also would include a collaboration component, Hlopick said. Nurses at many health care facilities feel divided from other constituencies, she explained. They often feel they are not part of the decision-making team and that their needs aren't completely understood. Being included as part of the collaborative planning team at the facility would alleviate many of these concerns.

"I believe [nurses] perceive leaders, managers, and nursing officers to be the voice for the hospital, not for them," she explained. "Nursing administration is working hard to close the gap between leaders and staff nurses and have developed strategies to increase staff nurse participation in unit decision making."

A long-range solution to the nurse staffing issues also would acknowledge these workers' need for growth, Hlopick said. "Opportunities for growth abound. A nursing degree is the entry point for jobs in education, leadership, research, and as a clinical nurse specialist or nurse practitioner. There are very few other fields that offer the same opportunity to expand into other areas."

An opportunity to serve patients, the chance to fully participate in hospital decision making, the potential to grow: these are among the factors that attracted Hlopick and others to nursing in the first place. But the "new" nursing environment—one altered by changing patient demographics, harsh economic realities, and other external pressures—may be failing to meet these personal needs.

The idea that Hlopick presented to CHA for its "Call for Innovative Ideas" centered on a nurse advocacy function that would, first, take an in-depth look at these concerns and others, and, second, serve as a voice for change on behalf of nurses. The concept is instructive for health care facilities seeking a comprehensive program for change.

Hospitals that allow nurses to advocate for themselves and to articulate their short-term as well as long-term needs will be the ones best equipped to deal with nurse shortages. Their solutions will include opportunities for nurses to devote themselves to patients, enhance their own personal growth, and fully participate in the hospital's development.

A Mission-Centered Approach
The "intangibles" that motivate nurses—a drive to connect with patients, a quest for personal growth, a need to participate in the team structure of the hospital—link nicely with most Catholic hospitals' mission statements.

For many such health care facilities, planning a response to the nurse staff shortages will require a close look at how well current and proposed policies and programs for the nursing staff measure up to the goals and values incorporated in the hospital's mission statement. Ensuring that the lofty goals of Catholic health care boil down to the "nurse-patient" level will help restore some of the "intangible" benefits that many nurses miss and that many recruits desire.

—Julie Minda


  1. Ernell Spratley, et al., The Registered Nurse Population, U.S. Health Resources and Services Administration, Washington, DC, 2000.
  2. First Consulting Group, quoted in AHA Commission on Workforce for Hospitals and Health Systems, In Our Hands: How Hospital Leaders Can Build a Thriving Workforce, American Hospital Association, Chicago, 2002, p. 10.


Copyright © 2003 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Making the Difference in Patient Care

Copyright © 2003 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.