Empty Hallways
Empty Hallways
The Hidden Shortage of
Healthcare Workers
A F
T
H E
A L
T H
C A
R E
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“Common sense tells us
there are a limited
number of patients a
nurse can care for safely, a
limited number of slides a
tech can read without
losing attention to detail,
a limited number of hours
a person can work
without becoming too
exhausted to function.
Unfortunately, common
sense rarely prevails”
SANDRA FELDMAN AFT President
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HE FACT THAT THERE IS A SHORTAGE OF NURSES WILL- ing to work in hospitals in this country is well
documented. Some hospitals are offering sign-on bonuses as high as $30,000 to lure experienced nurses away from other employers. The American Hospital Association (AHA) reports that 89 percent of hospitals report openings for RNs that are unfilled, and 75 percent of hospitals today are finding it more difficult to recruit nurses than in the past. The national vacancy rate for RNs is 11 percent, according to the AHA, and this shortage contributes to delays in care and makes it more difficult for some people to receive the care they need.
But the nurse shortage is only part of the story. Less pub- licized, but equally important, is the shortage of other health- care professionals. Hospitals nationwide report vacancy rates of 21 percent for pharmacists, 18 percent for radiology tech- nicians, 12 percent for laboratory technologists, and 9 per- cent for housekeeping and maintenance staff. Every health- care worker is an integral part of the healthcare system, and a shortage in any area creates problems for every other clas- sification of worker. Industrywide shortages such as those we are experiencing today create possibilities for delivering sub- standard, even dangerous, care to patients. Shortages also create a work environment that is not conducive to retaining the most qualified and experienced healthcare profession- als, resulting in a revolving door of workers.
AFT Healthcare looked at problems with recruiting and retaining nurses in a survey conducted in spring 2001 by Peter D. Hart Research Associates. The survey showed that many
FOREWORD
T
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2 E M P T Y H A L LW AY S
nurses who currently are not working in the profession would consider returning to direct patient care if certain conditions were met. Almost two out of three who had left said they would consider returning if there was better pay (23 percent), bet- ter staffing levels (21 percent) and better, more flexible, sched- ules (21 percent).
The survey results also showed that without these types of changes, one in five current direct-care nurses plans to leave the profession within the next two years, exacerbating an already dire shortage of nurses in our nation’s hospitals.
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UILDING ON THE FINDINGS OF THE 2001 SURVEY, AFT HEALTH- care commissioned Peter D. Hart Research Associ-
ates to conduct parallel surveys among three groups of health professionals: respiratory therapists, radiology tech- nologists and certified nursing assistants (CNAs) in spring 2002. The survey sought to determine if these health profes- sionals were experiencing the same types of workplace prob- lems as nurses and if recruitment and retention were prob- lems of concern. Interviews were conducted with 308 respiratory therapists, 302 radiology technicians and 302 certified nurs- ing assistants in states that require CNAs to be registered.
While each group of professionals had a distinct perspec- tive, what united them was their perception of a serious staffing crisis in their field. Here are the surveys’ key findings:
■ All three groups of professionals express low satisfaction with current conditions for health professionals, and point to inadequate staffing as the number-one problem they face.
■ Professionals report that staffing shortages are compro- mising the quality of healthcare provided, and even put- ting patients at risk.
■ Beyond the staffing problems in their own facilities, respon- dents perceive a broader shortage of qualified profes- sionals in their fields that is caused by unsatisfactory work- ing conditions. Indeed, inadequate staffing has itself become a cause of recruitment and retention problems.
4 E M P T Y H A L LW AY S
B
SURVEYING HEALTHCARE PROFESSIONALS
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E M P T Y H A L LW AY S 5
■ The solutions to these shortages identified by professionals include mandatory maximum professional-to-patient ratios, higher pay, improved health coverage, more sup- port staff, opportunities for continuing education and a stronger voice on the job.
The staffing problem within these three professions mir- rors that of nursing. The complex circle begins with inade- quate staffing, which serves as an impetus for workers to leave the profession, resulting in an even worse staffing situation. With proper staffing levels, workers tend to be more satisfied and less likely to leave. This is evidenced in the Australian province of Victoria where mandatory nurse-to-patient ratios recently were negotiated. Not only have more than 3,300 nurses who left the profession returned, but the use of agency nurses has almost ceased, and morale among Victoria’s working nurses has improved exponentially.
NO DEBATE: THERE ARE SHORTAGES
Health professionals experience the staffing crisis directly and personally. Every day, it reduces the quality of their work lives and constrains their ability to deliver quality healthcare. Yet given these results, it is clearly not a problem limited to certain facilities, professions or regions. There is a shortage of qualified professionals in all of these fields, and those work- ing in the field clearly recognize it.
Seventy-four percent of respiratory therapists report that there is a shortage of therapists in the area in which they live, including 33 percent who say the shortage is severe. Among CNAs, 79 percent report a shortage in their area, with 27 per- cent describing it as severe. The worst shortage appears to be in radiology, with 82 percent perceiving a shortage and fully 43 percent a severe shortage. Clearly, the healthcare system faces a widespread crisis in terms of hiring an adequate num- ber of professionals to meet the needs of patients.
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6 E M P T Y H A L LW AY S
RESPIRATORY THERAPISTS
There are about 100,000 respiratory therapists in the United States. They work
with patients of all ages and in many different care settings. Respiratory thera-
pists are members of the healthcare team that provides respiratory care for patients
with heart and lung disorders.
Most respiratory therapists work in hospitals where they perform intensive
care, critical care and neonatal procedures. They typically are also a vital part of
the hospital’s lifesaving response team that handles patient emergencies. Of the
more than 7,000 hospitals in this country, about 5,700 have respiratory care
departments.
RADIOLOGY TECHNICIANS
Radiology techs are the medical personnel who perform diagnostic imaging
examinations and deliver radiation therapy treatments. They may specialize in
a specific area of radiological technology – such as mammography, magnetic res-
onance, nuclear medicine, sonography, cardiovascular- interventional technol-
ogy, radiation therapy or diagnostic radiography.
Although the majority of radiological technologists practice within a hospi-
tal setting, many now work in private clinics or mobile facilities. There are more
than 220,000 registered radiology techs practicing in the United States today.
CERTIFIED NURSING ASSISTANTS
There are more than a million certified nursing assistants (CNAs) working in
hospitals and nursing homes around the country under the direction of nursing
and medical staff. They perform essential routine tasks such as serving meals,
making beds and helping patients eat, dress and bathe. CNAs may also take tem-
peratures, pulse, respiration and blood pressure. They often help patients who
need assistance walking, and they observe patients’ physical, mental and emo-
tional conditions, reporting changes to nursing or medical staff.
In nursing homes, CNAs are often the primary caregivers, having far more
contact with the residents than any other members of the staff. Some nursing
home residents may stay in one facility for months or even years and develop
ongoing positive relationships with the CNAs who care for them.
WHO ARE THESE WORKERS?
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A shortage can reflect problems in both recruitment and retention. It appears that both factors are at work in all three fields, but with notable differences. Radiology techs report that retaining qualified techs is a problem (44 percent cate- gorize it as being major or moderate), but consider recruit- ment to be the greater problem (64 percent). Similarly, respi- ratory therapists perceive a greater recruitment challenge (66 percent) than retention problem (44 percent). The situation is reversed for CNAs: Forty-six percent report a problem recruit- ing qualified CNAs, but 59 percent see a problem in retaining them. The fact that fully 29 percent of the CNAs have been working in the field for four years or fewer – compared to 6 percent of the respiratory therapists and less than 1 percent of the radiology techs – also suggests that high turnover is a problem in the CNA ranks.
The survey sheds some light on the underlying cause of these retention and recruitment problems by exploring the
E M P T Y H A L LW AY S 7
Shortage of Health Professionals
Yes, minor shortage Yes, moderate shortage Yes, severe shortage
Is there a shortage of [people in your profession] where you live?
Respiratory therapists
Radiology technologists
CNAs
74% 82%
79%
FIG. 1
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8 E M P T Y H A L LW AY S
job satisfaction of health professionals. All three groups express low levels of satisfaction and report poor morale among their professional peers. Clearly, these are not factors conducive to successful recruitment or to retaining the services of qual- ified professionals.
There are certain aspects of professionals’ work situations with which they express particularly strong dissatisfaction, and which therefore are likely to be important factors in caus- ing professional shortages. As Figure 2 reveals, these three groups of professionals express low levels of satisfaction with regard to a number of critical issues. Clearly, there are serious compensation concerns: professionals are not satisfied with salaries or – ironically enough – their own healthcare cover- age and costs. A rather lukewarm endorsement of retirement benefits is also offered by CNAs (42 percent satisfied), respi- ratory therapists (47 percent), and radiology techs (53 per- cent).
Low Satisfaction With Key Conditions
I am very/fairly satisfied with this aspect of my job:
Salaries
Workload
Health coverage/costs
Job-related stress
Staffing levels
Respiratory therapists
48%
46%
41%
39%
36%
Radiology techs
47%
56%
46%
39%
46%
CNAs
31%
42%
38%
46%
42%
FIG. 2
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THE STAFFING CRISIS
Health professionals paint a rather gloomy picture in describ- ing their current work environment. Only about half of res- piratory therapists (53 percent), radiology techs (53 percent), and CNAs (50 percent) are very or fairly satisfied with the con- ditions facing people in their profession today. Similarly, they report low morale among their fellow professionals. Just 38 percent of respiratory therapists say morale is excellent or good, while 62 percent say fair or poor (radiology techs: 49 percent fair/poor; CNAs: 45 percent fair/poor). These pro- fessionals are more likely to feel that conditions for health- care workers are getting worse rather than better: respiratory therapists (15 percent better, 56 percent worse), radiology techs (24 percent better, 47 percent worse), CNAs (26 percent better, 31 percent worse).
Respiratory therapists—Those in large hospitals (over 250 beds) are less satisfied with conditions and report lower morale than those in smaller hospitals.
Radiology techs—Morale is disproportionately low for those working in hospitals, and lower still for those in large hospitals.
CNAs—Sixty-two percent of those who see 12 or fewer patients per day report good or excellent morale, compared to 44 per- cent among those who see 13 or more patients per day.
E M P T Y H A L LW AY S 9
FIG. 3
Excellent Poor
Good Fair
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10 E M P T Y H A L LW AY S
A number of factors contribute to this bleak outlook, includ- ing concerns about compensation, benefits and voice on the job. However, the single most important problem facing health professionals is inadequate staffing levels. As Figure 5 shows, all three groups report that understaffing is the number-one problem they face. Many also point to not having enough time to spend with patients and job-related stress, both of which are closely linked to the staffing problem.
Only a minority in all three groups report that they are very or fairly satisfied with staffing levels at their facility, while a
FIG. 5
Inadequate Staffing Is #1 Problem
What are the two biggest problems for [your profession] today?
Staffing
Time with patients
Pay, benefits Advancement opportunities
Autonomy
Delegation of duties
Scheduling
Time for breaks
49%
36%
22%
14%
12%
8%
7%
6%
Staffing
Pay, benefits
Workload
Time with patients
Job-related stress
Physical work
Unsafe conditions
41%
27%
24%
22%
22%
8%
1%
Staffing
Pay, benefits
Time with patients Advancement opportunities
Scheduling
Asked to perform duties not trained for
Time for breaks
Autonomy
46%
46%
45%
9%
6%
6%
5%
5%
Respiratory Therapists Radiology Techs CNAs
FIG. 4
Getting better
Staying about the same
Getting worse
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majority of respiratory therapists (63 percent), CNAs (57 per- cent), and radiology techs (52 percent) say they are just some- what or not satisfied. For respiratory therapists, this is the low- est level of satisfaction recorded among 15 different aspects of their job.
Respiratory therapists—Seventy-four percent of those who work in large hospitals, and 67 percent of those who see 13 or more patients per day, express low satisfaction with staffing levels.
Radiology techs—Just 38 percent of techs in hospitals are satisfied with staffing levels.
The staffing crisis is a function of two powerful factors work- ing together. First, professionals are simply being called upon to serve more patients. Majorities of respiratory therapists (72 percent) and of radiology techs (69 percent) report that their patient load has increased in the last couple of years, while among CNAs a significant 35 percent minority say their patient load has increased. Virtually no one reports patient load having decreased over that time. Fully two-thirds of res- piratory therapists say they see more than 12 patients per day, and 57 percent of radiology techs see 20 or more patients.
Greatly magnifying the impact of this increasing ratio of patients to professionals is the increasing acuity or sickness of their patients. As a result of multiple changes in the health- care industry, the average hospital patient today is much sicker, and needs more care, than in the past. A majority of respira- tory therapists (73 percent) and radiology techs (51 percent), as well as a 47 percent plurality of CNAs working in hospitals, say that the acuity of their patients has increased during the past few years.
In addition to the shared experience of inadequate staffing, these three groups are also united when it comes to what they enjoy about their work as healthcare professionals. Over-
E M P T Y H A L LW AY S 11
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whelmingly, CNAs (81 percent), respiratory therapists (71 per- cent), and radiology techs (62 percent) point to “helping patients and their families” as the aspect of their job that brings them the greatest satisfaction. All three groups also cite chal- lenging and interesting work and the opportunity to work with colleagues they like as important benefits. However, their primary motivation is clearly service to patients and families.
Unfortunately, the ability of these healthcare workers to provide that service appears to be compromised by inade- quate staffing levels. One immediate and important effect of staffing shortages is that professionals have less time to spend with patients. CNAs (60 percent) and respiratory therapists (58 percent) both say this is a very or fairly serious problem for them. (Direct patient contact is less relevant for radiology techs.) Indeed, CNAs consider their inability to spend time with patients to be as serious a problem as low pay or inade- quate staffing, while respiratory therapists rank it second only to staffing.
E M P T Y H A L LW AY S 13
The Goal: Serving Patients/Families
What do you enjoy most about [your profession]?
Help patients and their families
Challenging/interesting work
Work closely with people I like
Professional autonomy
Continuously learning
Good salary and benefits
Respiratory therapists
71%
25%
20%
17%
8%
7%
Radiology techs
62%
27%
25%
11%
7%
13%
CNAs
81%
17%
33%
2%
19%
5%
FIG. 6
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QUALITY OF CARE SUFFERS, PATIENTS PLACED AT RISK
Of even greater concern, a majority of professionals in all three fields say that as a result of poor staffing and increased workloads, the quality of care patients receive has suffered. Seventy-nine percent of respiratory therapists, 71 percent of CNAs and 70 percent of radiology techs report a negative impact on the quality of patient care. Moreover, substantial proportions in all three professions report that patients may have been placed at risk as a result of staffing shortfalls (58 percent of respiratory therapists, 46 percent of CNAs and 37 percent of radiology techs).
Respiratory therapists—In large hospitals, 86 percent report an adverse impact on quality of care, and 67 percent say patients have been placed at risk.
CNAs—Of those with 13 or more patients, 80 percent say quality of care has been compromised, and 60 percent report patients may have been placed at risk.
Radiology techs—About 72 percent of those in hospitals say staffing has hurt quality of patient care.
14 E M P T Y H A L LW AY S
The Consequence: Quality of Care Suffers, Patients at Risk
79%
58%
70%
37%
71%
46%
Quality of care has suffered Patients may have been placed at risk
Respiratory therapists
Radiology technologists
CNAs
As a result of increased workload/poor staffing [in my profession]:
FIG. 7
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IMPROVING RECRUITMENT AND RETENTION
Despite professionals’ concerns about conditions in the workplace, the survey results suggest that there are ways to improve recruitment and retention. One step endorsed both by respiratory therapists and by CNAs is establishing manda- tory maximum patient-to-professional ratios. ( This idea is not particularly relevant for radiology techs who generally see a wide variety of patients from various units and with vary- ing degrees of acuity. Radiology techs supported increased staffing levels and workload limits that would provide a min- imum timeframe for various procedures.)
By an overwhelming margin, CNAs (88 percent to 7 per- cent) favor mandatory ratios. For CNAs in a hospital medical or surgical unit, the median suggested ratio is about 6:1. Fully 71 percent suggest a mandatory ratio of no more than 8:1. This stands in stark contrast to the current reality in hospi- tals, where fully 60 percent of CNAs say they currently care for more than eight patients at a time. In an intensive-care unit, most CNAs would set the limit at 4:1 or lower. In nursing homes, the median recommended patient-CNA ratio is between 7:1 and 8:1, and 87 percent say the ratio should be no more than 10:1. Again, current practice is clearly quite different: more than six in 10 (63 percent) nursing home CNAs report that they care for more than 10 patients during their shift.
Respiratory therapists also embrace the idea of mandatory ratios (67 percent to 23 percent). The median recommended ratio for a hospital medical or surgical unit is approximately 10:1, with 63 percent saying the ratio should be 12:1 or lower. However, two-thirds of therapists (67 percent) report that they now see more than 12 patients per day.
Health professionals also support a range of other steps as effective solutions to the recruitment and retention challenges facing their professions. Improving compensation packages ranks very high on their list of priorities. More than 85 per-
E M P T Y H A L LW AY S 15
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cent in all three professions say that raising salaries would be a very or fairly effective way to better recruit and retain qual- ity professionals. More than 70 percent say the same thing about improving health coverage.
But professionals are looking for more than fair salaries and good benefits. They also point to such reforms as giving professionals more input in decisions affecting the workplace, hiring more support staff, providing opportunities for con- tinuing education, and instituting more flexible schedules as important steps to take. Improving staffing ratios is consid- ered to be an effective step for improving retention and recruit- ment by CNAs (91 percent), respiratory therapists (78 per- cent) and radiology techs (68 percent). This step would reverse the “vicious cycle” of inadequate staffing leading to a wors- ening shortage of professionals and, instead, replace it with a virtuous cycle of improved staffing, better conditions and more successful recruitment.
These findings are important because they indicate that although the professional shortage is clearly a serious prob- lem, it is not an insolvable one. If hospitals and other health- care providers improve conditions for health professionals, these survey results suggest that it is possible to make real progress in providing Americans with the quality professional healthcare that they need and deserve.
16 E M P T Y H A L LW AY S
Retention and Recruitment This would be a very/fairly effective way to improve recruitment/retention of [people in my profession]:
Raise salaries
Improve staffing ratios
Better health coverage
More input in decisions
Flexible schedules
Support staff
Continuing education
Respiratory therapists
86%
78%
74%
74%
60%
57%
57%
Radiology techs
86%
68%
71%
66%
70%
63%
69%
CNAs
91%
91%
78%
76%
70%
75%
76% FIG. 8
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FT HEALTHCARE ADOPTED A SERIES OF RECOMMENDA- tions in 2001 designed to help stem the national nurse shortage. Chief among them was the
adoption of specific recommended hospital nurse- to-patient ratios by unit (see Appendix).
Likewise, AFT Healthcare strongly supports the adoption of federal standards outlining worker-to-patient ratios and workload limits for all healthcare workers. Healthcare employ- ers must be required to provide adequate staffing levels and appropriate skill mix to ensure quality care to patients and a safe work environment for caregivers.
Further, AFT Healthcare supports a legislative ban on mandatory overtime for all healthcare workers. No workers should be forced to work past a scheduled shift, especially those who are responsible for making life and death decisions concerning patients who depend upon them.
Finally, healthcare workers should be adequately com- pensated through higher salaries and improved benefits. While working conditions have continued to deteriorate for health- care workers, so have wages and benefits. Healthcare employ- ers generally spend less per employee on benefits – particu- larly on pensions – than do employers in other industries.
E M P T Y H A L LW AY S 17
RECOMMENDATIONS
A
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POSITION STATEMENT ON SAFE STAFFING
Appropriate staffing levels in hospitals and other health- care facilities are crucial to maintain the highest level of qual- ity patient care. There is a great deal of debate both within the industry and outside about what constitutes “appropriate lev- els” and by whom they should be determined.
It is indisputable that changes have taken place in the healthcare industry over the past decade and that these changes have altered the way healthcare services are delivered. Fewer patients are admitted to hospitals. Those that are tend to be more acutely ill and stay for shorter periods of time. Hospi- tals and other healthcare facilities are competing for lucra- tive insurance contracts, forcing them to cut costs, which often means cutting staff. Yet, by cutting staff levels inappropriately, patients are not receiving the type and quality of care that they need and deserve.
There are several things to keep in mind when determin- ing staffing levels in healthcare:
■ The type of healthcare facility and the types of patients
it serves. Not only does the type of healthcare facility affect the type of staffing levels that are appropriate, but so also do each facility’s location, number of beds (or residents or clients), occupancy rate and teaching status. Each of these factors must be taken into consideration when deter- mining what is a safe and appropriate staffing level.
■ The acuity levels of patients. As cost-cutting measures are implemented in every facet of healthcare, more and
18 E M P T Y H A L LW AY S
APPENDIX
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more services are being performed in non-acute care set- tings. Surveys of nurses and other healthcare providers attest to the fact that patients in hospitals are more acute than ever before, even though their lengths of stay have decreased. Likewise, patients seen in outpatient settings and in their homes also tend to be more acute.
■ The skill mix of those providing services to patients.
There is a significant body of research linking staffing ratios of registered nurses to patients with higher quality care. However, it is important to not overlook the important impact that LPNs, nursing assistants, lab techs, x-ray and radiology techs, respiratory therapists, pharmacists and other healthcare workers have on quality outcomes. Not only is it imperative to have adequate nurse staffing, but adequate ancillary staffing is as important.
Given these parameters, AFT Healthcare has adopted the following principles as related to safe staffing in healthcare:
■ Healthcare facilities should adopt standardized nurse-to- patient ratios that are established in joint labor-manage- ment committees in unionized facilities or by the U.S. Depart- ment of Health and Human Services. These ratios should always take into consideration, and may include actual staffing ratios, for other caregivers and ancillary staff.
■ In facilities that do not have a union contract outlining staffing levels, the following minimum RN-to-patient ratios should be mandated:
1:4 med surg 1:2 ICU/CCU 1:1 operating room 1:2 neonatal ICU 1:4 intermediate care nursery 1:8 well-baby nursery 1:8 postpartum, with 1:4 couplets and 1:6 in units with
mothers only
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1:2 labor and delivery 1:2 post-anesthesia care 1:4 emergency, with 1:2 for critical care and 1:1 trauma 1:2 burn unit 1:4 pediatrics 1:4 step-down/telemetry 1:5 specialty care/oncology 1:5 telemetry 1:6 behavioral health psychiatric units
■ In addition to minimum ratios, staffing should be deter- mined based on the acuity of patients. Any acuity system developed by an employer should include the input of front-line nurses and other caregivers. Acuity systems should not be changed arbitrarily by an employer who fails to meet its own staffing guidelines. Any changes in such a system should be done in a collaborative fashion between management and its employees through labor- management committees.
■ Hospitals and other types of healthcare facilities should disclose to the public their staffing levels for every unit and every shift. This list should include all workers, licensed and unlicensed and the methods used to determine and adjust staffing levels in that facility. It should also disclose patient care incidents such as medical errors, decubiti, and nosocomial infections on a monthly basis. The pub- lic should be aware of inadequate staffing levels, and also of proper staffing levels, in order to make informed deci- sions regarding their own personal heath care.
■ Safe staffing includes not only the number of registered nurses available to care for patients, but also must take into account the education, experience and expertise of the nurses. Safe staffing must include time for proper train- ing and orientation and should forbid mandating nurses to practice in areas outside of each individual’s area of expertise, skill and knowledge.
20 E M P T Y H A L LW AY S
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Candice Owley, Chair President, Wisconsin FNHP
Ann Twomey, Vice Chair President, Health Professionals and Allied Employees (HPAE)
Sylvia Barial
Chair, School Nurse Chapter, United Teachers of New Orleans, Local 0527
Ora James Bouey
United University Professions, Local 2190
June Edwards
Public Employees Federation, Local 4053
Carol Flynn
Treasurer, Danbury HPNA, Local 5047
Anne Goldman
Special Representative, Federation of Nurses/UFT, Local 0002
Ralph Hickle
President, Healthcare-PSEA/FNHP, Local 5120
Jacqueline Himes
Executive Board Member, Philadelphia Federation of Teachers, Local 0003
Debra Perry
President, Maryland FNHP, Local 5197
Kathy Petrin
President, Oregon FNHP, Local 5017
AFT HEALTHCARE PROGRAM AND POLICY COUNCIL
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A Union of Professionals
AFT Healthcare is a division of the American Federation of Teachers, AFL-CIO
555 New Jersey Avenue, N.W. Washington, DC 20001
202-879-4400 www.aft.org
ASK FOR ITEM NUMBER 67-FN-0034
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