FEATURE ‌ Critical Condition 

S.C.'s nursing shortage could use some intensive care

7a.m. The day starts early for Misty Deason in the Medical ICU ward at MUSC Hospital.

She typically has two patients to care for in her 12-hour shift, but at 7 there is only one. The patient in Room 9, a 57-year-old woman, died from complications of cancer at 6 a.m. The family is still with the body in the closed room.

Deason's priority now is Patient 10, a 61-year-old woman with a history of myeloma. The disease knocked her white blood cell count down and wrecked her immune system, resulting in pneumonia. She is now on a ventilator, fighting for her life. Behind her bed is a battery of IV pumps and electronic monitors reporting her body functions, her respirator, and kidney output.

Deason must make a full assessment of her surviving patient at the beginning of her shift. But she is not through with Patient 9. She notifies the hospital morgue to remove the body, then pulls together the large volume of paperwork on the deceased patient and prepares it for the records department.

There are supposed to be eight nurses on the floor to staff the 13 MICU rooms. Today there are only seven, so charge nurse Terry Connor will take a patient with renal failure, in addition to her regular duties overseeing and assisting the other nurses. Another nurse will take a third patient to fill the gap. Short staffing is business as usual in the MICU and nobody seems to give it a second thought.

As anyone who has stayed in a hospital lately can probably tell you, there is a nursing shortage. It touches every corner of the national health care system and South Carolina is no exception. Nationwide, 75 percent of all hospital vacancies are for registered nurses. According to the Bureau of Labor Statistics, there will be a shortage of one million nurses in 2010.

"When you come into a hospital, doctors will see you for 10 minutes a day," says Gail Stuart, Ph.D., Dean of MUSC's College of Nursing. "Nurses are the ones who keep patients alive."

There are currently about 32,300 registered nurses working in the state, Stuart says. The shortfall is anticipated to peak between 2015 and 2020, with a dearth of some 15,000 nurses -- or about 18 percent of the needed workforce. South Carolina currently ranks 42nd in the ratio of nurses to general population.

The shortage is the result of a perfect storm of circumstances, all of which were foreseen long ago, but none of which have been addressed on a national scale. First, there is the glut of aging baby boomers, who will soon be pouring into the nation's retirement homes and ICUs. Their conditions will be more complex and demanding than the conditions of a younger population.

Then there is the nursing workforce itself, which is also aging. Close to 70 percent of South Carolina's nurses are over 40. Thirty-three percent are over 50.

There is an irony in the nursing shortage, Stuart says. "We used to have a shortage of students. Now we have a shortage of faculty."

A generation ago, women -- who still make up the vast majority of the nurse workforce -- started leaving the field to go into business, technology, and other areas once largely closed to them. Nursing schools began to contract, and in the 1990s women began to hit the glass ceiling in their new fields and started coming back into nursing, but things had changed.

Today qualified candidates are lining up at MUSC College of Nursing and other nursing schools in the state. Yet the Southern Regional Education Board reports that 1,100 qualified students were turned away from nursing programs in South Carolina in 2005 due to lack of faculty. Faculty shortage has become the primary bottleneck to the training of more nurses in the state. And until the state increases faculty pay, that will remain a problem.

To teach nursing a faculty member must have at least a Master's degree in the field. While the pay for clinical nurses has stayed competitive, it has stagnated for nursing faculty. The American Association of Colleges of Nursing reports that nursing faculty are paid as much as $30,000 less than clinical nurses with comparable education.

But the nursing shortage is about more than the absolute number of RNs. It's about the kind of RNs, Stuart said. There are 25 schools in the state with nursing programs. Most of those are 2-year technical college programs, offering associate degrees. Today, 75 percent of nurses in the state have associate degrees, yet national accrediting agencies recommend that no more than 33 percent of the work force should be associate nurses. The rest should have baccalaureate degrees or more.

"In other words," Stuart says, "we're going in the wrong direction."

The nursing shortage in South Carolina is about to get worse, the result of the state's disjointed health care system. When a hospital wants to expand, it must get certification from the Department of Health and Environmental Control. But neither it nor DHEC engages with the nursing community to determine availability of nurses to staff the new beds. More than 400 new hospital beds are scheduled to come online in the state in the next two years. No one has asked where the nurses will come from.

In fact, 40 percent of South Carolina's nurses come from out of state. To cover the RN vacancy rates in 2004, South Carolina hospitals spent over $77 million on agency and traveling nurses to provide adequate patient care.

The nursing shortage is one of those largely invisible problems that people -- especially hospital administrators -- don't talk about for fear of scaring people away, Stuart says.

"We know this is a problem," she says. "When does it become a crisis? You don't know it's a crisis until you go into a hospital and encounter a serious staffing shortage."

After checking the monitors and conducting a blood-gas diagnosis, Deason determines that Patient 10's blood CO2 is high and her pH is low. She mixes medications, draws them into a large syringe, and injects them into one of the many tubes running in and out of the woman's body. She records all this in Patient 10's thick book of records on her desk.

By now the grieving family has left Room 9. Deason goes to the storage room -- the Pyxis room, it is called -- where supplies are kept and everything is electronically monitored by a Pyxis computer system for future billing purposes. She takes a clear plastic body bag and carries it into the room with the deceased patient. Then she sits down to get some paperwork done, but before she can pick up the pen, another nurse approaches from Room 12 to ask for assistance in calculating the output on a patient's dialysis machine. It's part of the constant balancing act as nurses try to cover all the bases in a perpetual shortage.

It was a personal crisis that led Misty Deason into nursing. She had a degree in psychology from the College of Charleston when her son Colin was born seven years ago with a congenital heart defect. He underwent the first of a series of operations when he was four days old. In the months and years of pediatric care, she came to know his nurses well and was deeply moved by their skill and compassion. "Nurses are cool," she says, remembering that experience.

She decided to make a career change. With her background in psychology, she took a course in anatomy and a course in microbiology, qualifying her for the fast-track program at MUSC College of Nursing. With 18 months of intensive work, she received her Bachelor's degree. Following a brief stint in Neonatal ICU, she transferred to Medical ICU, where she has been very happy for two years.

The nursing shortage has led to some startling discoveries in the way nurses affect patient outcomes and the American health care system.

Having more nurses on hospital units is linked with better hospital outcomes, according to Medical Guidelines and Outcomes. The New England Journal of Medicine says that more hours of nursing care are associated with better outcomes for hospitalized patients. And The Journal of the American Medical Association reports that units staffed by nurses with baccalaureate or higher degrees had lower patient mortality. Other studies show that 24 percent of patient injuries and deaths are due to low levels of nursing staff.

These studies prove that quality nursing care is critical to creating and maintaining a quality health care system, Stuart says.

But there are serious barriers to attracting and keeping nurses in the field. These include the outdated perception of nurses as hospital "go-fers" and a traditional antagonism between nurses and doctors, which nurse Aubrey Wade referred to in the February 9, 2006, issue of Synapse, when she wrote of "the stereotypical patronizing attitude from doctors to nurses, the condescending dismissal that can bother some nurses so much that they must leave the clinical environment to preserve their self-respect."

These images are bound up in the fact that 90 percent of nurses are still women and many men seem uncomfortable taking on this traditional distaff role, even as the genders have evened out at 50-50 in med schools.

Yet there are strong incentives for entering the nursing profession, including flexible schedules and a wide variety of fields in which to practice. The image of nurses is enhanced by the high level of training they receive and the high-tech roles they play in the modern health care system. And the pay is good -- very good, according to Stuart. Entry level salary for a baccalaureate nurse is about $45,000. A master of nursing will start at about $75,000. A doctor of nursing can make more than $115,000.

Dr. Winnie Hennessey is a freshly minted Ph.D. nurse who teaches a class in Palliative and Supportive Care at MUSC College of Nursing. On a recent morning she instructed a class of rapt baccalaureate students in the art of helping the terminally ill cross the line between life and death with dignity and peace. Her manner was warm and even humorous, but the business at hand was deadly serious, as she discussed a dizzying array of symptoms, conditions, medications, procedures.

"There's a physiology associated with dying, like there is a physiology associated with being born," she said. "It takes nine months of pregnancy to get born. It takes three to six months to die."

There were 41 students in this advanced class. One was male; three were black.

Hennessey is a New York City native who has been in the nursing field for more than 30 years. She got her Bachelor's degree in nursing in 1979, her Master's in 1997 and her Doctorate at MUSC last fall. Her curriculum vitae runs more than 10 pages.

"I am, by nature, more of a global thinker," she said in a telephone interview. "Caring for patients is more than just ordering a drug. It's applying what you know respective of who they are and the way they live."

Her "global thinking" comes from a career that has spanned the continent and placed her in such diverse fields as cardiology, digestive disease, and surgical intensive care. Her name is on more than a dozen journal articles and other publications. Now she is training the next generation of nurses who will face the tidal wave of aging baby boomers.

The director of the Medical ICU, Dr. Alice Boylan, makes her morning rounds with a clutch of residents and interns following on her heels like ducklings. The morgue has removed the body from Room 9 on a specially cloaked gurney which conceals its cargo. Now Misty Deason assists an orderly in stripping the bed, turning off monitors and disposing of used IV tubes, bags and other containers. Time is critical. The new Patient 9 will be arriving soon.

She sends the old Patient 9's paperwork to the records department and stops to consult the pharmacist on medications for Patient 10. She makes further notes, then hooks the patient up to another bag of antibiotics.

There is enormous paperwork in this job. The most annoying is the business of handling controlled substances. Patient 10 is connected to a bottle of Fentanyl, a painkiller which assists her in breathing. When Deason hooks up a new bottle, she must dispose of the fraction of an ounce remaining in the old bottle, which has expired. To do this, she fills out yet another form, pours the old drug down the drain, hangs the new bottle of Fentanyl and does it all in the presence of a fellow nurse, who signs the form as a witness.

"It's just endless paperwork," she says.

But she loves what she does. And she says, "I love my patients."

Deason's next patient is wheeled into Room 9 at noon. He is 73 years old with a history of strokes. She immediately connects his IV tubes and inserts his ventilator tube, pulls up his eyelids and examines his pupils with a flashlight, and uses an electronic monitor to check for a pulse in his feet.

She then goes to the IV pump at the head of the bed and watches his blood pressure on the monitor. Patient 9 is on two pressors -- Levophed and Vasopressin -- to raise his blood pressure, but they do not seem to be working. She adjusts the IV drips, but still no improvement in the numbers. Patient 9 is receiving maximum doses of both pressors and his pressure is still dropping.

Deason summons Dr. Susan Datta, who comes to the bedside and immediately writes an order for another pressor -- Dobutomine. Only then does she discover the origin of the problem. Somehow the IV catheter had become dislodged from the patient's left jugular vein. As a result, he is not receiving his medication.

Datta goes to work to insert another catheter. Over the next minutes the tiny room fills up with nurses and residents, assisting and observing. Everyone dons blue surgical masks; a blue surgical cover is placed over the patient. Datta uses an ultrasound device to locate the vessel she wants to use, then inserts the catheter.

The procedure takes barely 15 minutes. When it is over, everyone files out of the room except Deason, who remains by her patient's side, watching with satisfaction as his blood pressure inches upward on the monitor.

Recruiting and training nurses is about more than health care. It's about economic progress in South Carolina, and Gail Stuart never misses an opportunity to make that point.

In a column she wrote for the Post and Courier last May, she cited a 2003 study in the Health Care Manager, which estimated that the total value of a hospital to a region could be as much as $1,655,046,692 through its roles as employer, health care provider, and community leader. But to fully perform its role, a hospital must be fully staffed, and 75 percent of all hospital vacancies are for RNs, Stuart wrote.

"These economic benefits are felt at each level of the economy, from the individual consumer through the corporate offices," she wrote. "Specifically, companies interested in potentially relocating to this state carefully consider the quality of health care available to their employees. The nursing shortage has a negative impact on the quality of health care available in this state and thus may even turn away potential industries and investors."

Stuart doesn't just talk -- she acts.

In 2003, she organized the South Carolina Nursing Collaborative -- a group of six hospitals and MUSC -- with the purpose of hiring more faculty and increasing class size. So far, she has raised $4 million in state and private funding, allowing the college to double the number of baccalaureate nurses it graduates each year, from 50 to 100.

Perhaps more important is the online academic program the MUSC College of Nursing initiated four years ago. The program allows faculty to deliver their nursing curriculum in a cost-effective manner to off-site students throughout the state. The online program includes assigned readings, podcast lectures, and films, Stuart said. "There is no passive participation in this learning process. Every student must respond to the technology to be a part of the process."

Starting with only 20 students in 2003, the online curriculum trained 60 nurses last year. More recently, the college made its doctoral program available online.

Today the South Carolina Hospital Association is lobbying the General Assembly with a sophisticated program called One Voice/One Plan. The goal is to convince the legislature to hire as many as 66 new nursing faculty positions statewide by 2010 and attract those faculty with salary enhancements. It also calls for new scholarships, loans, and grants for qualified nursing students and an Office of Health care Workforce Data and Research, a critical tool in anticipating health care needs and creating policy in South Carolina.

The health of millions of South Carolinians depends on how the General Assembly meets the challenge of One Voice/One Plan.

The health of Patient 9 is precarious. Since getting his new IV catheter inserted, his blood pressure has stabilized, and Deason took the chance to go downstairs and get some lunch. Other nurses covered for her, of course, as she has covered for them to take a break. Now she is back, checking Patient 9's feeding tubes and the residuals in his stomach.

She is interrupted by a beeping sound from one of Patient 10's monitors. She responds by aspirating the air out of the patient's ventilator pump and the problem is solved.

"This is not a sexy job," she says, as the clock ticks down the 12th hour of her shift. "Grey's Anatomy is sexy, but they will never do a TV show about nurses ... People think that nurses just deliver pills and give baths, but it's nothing like that. This is not a TV show. The doctors don't do everything. We have a lot of autonomy in recommending and acting in an emergency.... It's a very satisfying job."

Was it a good day?

"It's always a good day if both of your patients are alive at the end of your shift."


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