The Brewing Crisis in Health Care, Part II-Nurses!

By: Dr. Frank MacMillan – August, 2016
(*Erica MacMillan contributed to this column.)

Writing from the perspective of a practicing medical doctor, I have had 21 years with the MD credential after my name, and have had the good, the bad and the ugly that goes with it. Understanding that I live in a world that is privileged, I am not going to be one to complain about the troubles that my profession is dealing with, but from the perspective of a human being who is also aging and threatened by health issues like everyone else, I want you to be aware of some of the issues looming.

I am one of the remaining doctors who still spends a lot of time seeing patients at the local hospitals. On a daily basis, I depend upon other non-physician professionals to provide health care services to people. Most of those professionals are nurses. Nurses perform a variety of different roles within the world of health care. The most highly trained are the advanced practice nurses (nurse practitioners, nurse anesthetists, nurse midwives), who function in teams with physicians to provide direct health care services. The BSN-RN or bachelor-prepared nurses are nursing providers who perform most of the services that we identify with nursing care including ICU and Emergency care, as well as manage complex infusions, ventilators and care usually called advanced life support. The most common nurses in other settings are the Registered Nurses with an Associate degree (ASN-RN). The ASN-RN usually has a two year degree and more “skill-based” training, as opposed to the “research-based” training that the BSN-RN’s have. The LPN or licensed practical nurse, may train for 12 or more months.

You will find LPNs often in a physician office setting or a skilled nursing facility. They also work in hospitals, but have a more limited scope of practice. All of these providers have “nurse” as their title, but their roles are more precisely defined by their level of education, which is not always apparent to the patient being treated.

There is a real and worsening shortage in nursing care in the United States, and this is a very under-reported and unappreciated story that will affect us and our loved ones. The causes of this shortage are many. One is a lack of nursing educators, because real nurses are required to teach nursing students. Nurse instructors will generally require a Masters Degree at a minimum, and they take a significant pay-cut when they perform education duties, compared with direct patient care. For a nursing program to maintain accreditation there must be minimum number of Masters, PhD and DNP (Doctor of Nursing Practice) nurse educators as faculty. The second issue is the availability of hospital training slots for prospective nursing students. Clinical sites can only take so many nurses on a clinical floor. Hospitals typically balance and try to accommodate students from multiple schools of nursing.

This creates a natural cap on the number of nursing students a school can place into clinical rotations for mandated experience and training. Thirdly, because of increased technology, nurses are spread more thinly. Remote monitoring of patients through telemetry and other automatic technologies allows a nurse to take care of a greater number of individual patients through real-time monitoring, but has the downside of less individualized care. It also makes it seem that patients are better attended to. The promise of technology may be undermining the humanizing care provided by these dedicated professionals and mask the shortage of these skilled men and women. Lastly, there is the revolution occurring in computerized medical records in the outpatient and hospital settings. Although billed as a major improvement in safety and quality, the real world experience is mixed. The number of hours in the day dedicated to patient care now competes with the necessary documentation that nursing staff must do in order for their employers to be paid by government and third party payers for the services that they render.
More recently, hospitals are requiring that their ASN-RNs pursue Bachelor level credentials because accreditation organizations are requiring more attention to “evidence–based practice.” What this really means is that our two year RNs are becoming obsolete because research-based training is now deemed necessary for comprehensive patient care. Hospital systems are essentially phasing out current ASN-RNs because of the lack of research training. New hires are being required to upgrade their credentials within a certain time-frame, and some existing ASN-RNs are being required to obtain additional education or lose their jobs. People do not choose the ASN-RN to shorten their pathway to a good job. Often these graduates are from community college backgrounds or there were not enough BSN slots to accommodate them. Their bedside skills and clinical acumen are often at an equivalent level to the BSN-RN with regard to direct patient care. In my opinion, they are being placed at a disadvantage that is undeserved, and are put in a financial bind, midcareer, to acquire additional education credentials to keep their jobs which marginally add to their ability to provide excellent direct patient care.

To get back to the original point, similar things are burning out both physicians and nurses. We are all dedicated to providing the best of care to you and your families. We are in the perfect storm of a demographic bubble where more people than ever are requiring care, and there are major revolutions in how we provide that care. More regulations and mandated changes are resulting in fewer doctors and fewer nurses available to provide the needed care. How we navigate the existing shortage of both doctors and nurses should be the most important priority of health care reform. As it turns out, recent iterations of so called health care reform are focused on mostly documenting and “quality” reporting.

We all know that what gets paid for is what gets done, and all of those reporting mandates are being loaded onto our nurses and physicians taking care of us. Since the great recession, our government has not “let a good crisis go to waste,” and has used its newly won powers to control payment for health care services, but now conditioned on mandated government reporting. Fewer nurses are caring for more patients, but are also being burdened with new mandated education and documentation requirements.
In my 21 years of being a medical doctor, I cannot remember hearing so many of my nursing colleagues confess that their profession is in crisis. Older nurses are retiring in droves. Mid-career nurses are burning out. My ability to do what I do is nearly impossible without the collaboration of the outstanding staff nurses across the spectrum of nursing practice that I work with on a daily basis. We know the causes of the crisis. Just ask a nurse. But also ask our political leaders… Who will be there to train and mentor the next generation of nurses?

Dr. Frank MacMillan, Jr, MD, FACG specializes in Gastroenterology and Liver diseases, is a Fellow of the American College of Gastroenterology and it’s Massachusetts Governor. He is Vice President of the Massachusetts Gastroenterology Association. Dr MacMillan is a native of North Andover and practices Gastroenterology in Haverhill at Merrimack Valley Hospital, where he currently serves as the Chief of Medicine. He has also been a member of the North Andover Board of Health since 2007. You can email Dr. Frank at 
“Erica MacMillan is a currrent BSN nursing student anticipated to graduate in May, 2017. She was raised in North Andover and currently resides in Florida.”