Practices feel pain of industry-wide nursing shortage
From the September ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.
By Bryan Walpert
Summit Medical Associates has never had so much trouble hiring and retraining nurses.
The 12-physician internal medicine practice in Hermitage, Tenn., lost a licensed practical nurse (LPN) and two registered nurses (RNs) early last summer. The LPN took an administrative job, while the RNs moved to higher-paying jobs at a specialty practice and a hospital.
Administrator Patricia Brown need only glance at the classifieds to see why replacing the staff has proven so difficult. Hospitals are offering $40 an hour for RNs and $30 for LPNs, and they're giving signing bonuses of up to $5,000. "It's horrible," Ms. Brown explained. "It's not just competitive, it's cut-throat."
She's not the only one feeling the pinch. A June report by the New York bond-rating firm Fitch Inc. projected a shortfall of 1 million nurses by 2010 and 1.5 million by 2020.
Analysts say a number of factors are at work. First, the growth of the elderly population is creating an increased demand for services. Making matters worse, experienced nurses are either retiring or leaving the field because of job dissatisfaction.
Finally, fewer young women are joining the field because they have other career options. For a field that is still dominated by women-only 5.9% of working RNs were men in 2000-that spells trouble. "We're never going to reach the numbers of nurses we need until we get more of a gender balance," said Patricia Starck, dean of the school of nursing at the University of Texas Health Science Center at Houston.
Nursing schools are working to recruit more men to the field, but those efforts won't help the current shortage. About 80% of hospitals already have reported a shortage, according to Fitch. In June, the American Hospital Association reported about 126,000 unfilled RN positions.
No one is sure how the shortage is affecting medical practices, because data are not readily available. Anecdotal evidence, however, indicates that the nursing shortage rippling through hospitals across the country is trickling down to at least some internal medicine practices.
Some practices report that they are waiting longer for the right applicant-and paying higher salaries to attract them. "From a private practice standpoint, we're having significantly more difficulty recruiting and retaining nurses," said David Colaiuta, an attorney and consultant with The Health Care Group, a consulting firm in Plymouth Meeting, Pa. The shortage is not necessarily limited to RNs. Some practices say they are having difficulty finding good medical assistants (MAs)-and paying more to recruit them.
As for LPNs, physicians "are just not able to find them" said Charlene Barbour, executive director of the National Federation of Licensed Practical Nurses in Garner, N.C. "We have had more calls from physicians in the past 12 months than we have had in the last 10 years."
The good news for physicians is that the nursing shortage is not as acute for them as for hospitals. For some time, physicians have been shifting lower-level services like taking vital signs from nurses to medical assistants.
Nevertheless, physicians often need RNs to supervise clinical staff and perform higher level services. Ms. Brown of Summit in Tennessee, for example, said that her practice lost an RN who ran treadmill stress tests, a procedure that only an RN is qualified to perform. Her nursing staff supervisor has temporarily taken over that job.
Some practices report trouble finding replacements for clinical vacancies. Back in 1999, West Georgia Urology Associates in Carrollton, Ga., hired two LPNs through word of mouth. This summer, however, that method did not produce a much-needed LPN for the three-physician practice. And a newspaper advertisement that ran for several weeks prompted only a few responses from medical assistants.
Virginia Physicians, a 50-physician multispeciality group in Richmond, used to draw nine or 10 applicants when it had a nurse vacancy. Today, the practice is lucky to attract three or four candidates. John Daniel, FACP, a general internist with the practice, explained that several of the group's nurses have left for other types of positions. He personally lost an RN this spring to an insurance company.
"There are many administrative jobs for nurses that provide good pay and a little more flexibility," Dr. Daniel said. "It makes the situation harder. Patients get as attached to a nurse as they do to a doctor."
Experts say that despite these problems, practices actually may have an edge recruiting nurses during shortages. That's because some hospital nurses are willing to take a pay cut in exchange for the higher quality of life in private practice. They get to know patients, work for a single physician and have regular hours that rarely require weekend and evening work.
Still, Mr. Colaiuta said, the shortage is driving up wages. The average RN with less than two years of experience earned $17.61 at a physician practice in 2000, up from $15.08 a year earlier, according to statistics from The Health Care Group. Salaries for LPNs with about two years of experience jumped from $10.75 to $12.12, while MA salaries rose from $9.46 to $10.54.
Thomas Lineberger, MD, a solo internist with three nurses, shares office and staff expenses with another solo internist in Aberdeen, N.C. While he declined to divulge his nurses' wages, he explained that the practice pays an "exorbitant amount" because it has to compete with a local hospital.
"It's been worth every bit of it to me," he said. "I understand a lot of other doctors don't pay as well, so our nurses are happy to stay here. And we're happy to have them."
Robyn J. Levy, MD, a solo allergist in Atlanta, spent half a year trying to fill two nursing staff slots. She received resumes that were riddled with grammatical errors from job-hoppers or nurses who lived too far away to commute.
In June, she finally found an RN who responded to a newspaper ad and an MA through an agency. Along the way, however, she paid thousands of dollars in ads and nearly $4,000 to the agency. While the RN took a pay cut because she was burned out from hospital work, Dr. Levy said that she still pays her more than she paid nurses in the past.
Problems at hospitals
Physicians may complain about higher nursing salaries and problems filling open positions, but the shortage at hospitals is also affecting them in more subtle ways.
George Shannon, MD, an internal medicine and family practice physician with Horizons Diagnostics in Columbus, Ga., said that area emergency rooms have been diverting ambulances to other facilities because of staff shortages. As a result, he has had to spend time on the phone with insurance companies explaining why a patient has not gone to the approved hospital. While it's a minor inconvenience, it takes time away from patient care.
Dr. Shannon has also been getting more phone calls at the end of nursing shifts from nurses who are simply too busy to call earlier in their shifts. As a result, he said he has been getting more calls at inconvenient times like 7 a.m., when he is in the middle of morning rounds.
Dr. Daniel of Virginia Physicians also reported getting more phone calls from nurses. He said that he gets the most calls during weekends because nursing staff are generally not up-to-date on his patients. Some are per diem workers from agencies, while others only work weekends.
He recalled that one weekend this summer, for example, he had to contact a patient scheduled for surgery on Monday because the nurse on duty couldn't answer the patient's questions. "The nurse would have known what to do if she had been there all week," he said.
Bryan Walpert is a freelance writer in Denver.
Tips for finding and keeping nurses in a competitive job market
Here are some tips to help recruit-and retain-nurses and other clinical staff:
- Use nurses only for nursing. Certified medical assistants are able to handle many office duties such as taking vitals and escorting patients, said Gary Matthews, president of Physicians HealthCare Advisors in Atlanta. Registered nurses, on the other hand, are better suited for higher level work such as histories and physicals, triaging patients over the telephone and checking test results for physicians.
Offer competitive salaries. You won't win the deep-pocket game with hospitals, but consultants say you should get as close as you can.
"In the past, the difference in work environment meant differences not only in dollars, but also in benefits," said Charlotte Kohler, RN, president of Kohler HealthCare Consulting in Woodstock, Md. "But physicians can't turn a blind eye to wages like they used to. Office practices can be at the lower end of competitiveness, but they can't be off the mark."
Offer flexible hours and benefits. Some applicants are looking for a few hours a day or a week to supplement their hospital job, said David Colaiuta, an attorney and consultant with The Health Care Group, a consulting firm in Plymouth Meeting, Pa.
Applicants with other health insurance coverage-through a spouse, for example-may prefer dental, life, disability, or supplemental insurance, which covers out-of-pocket medical expenses, Mr. Colaiuta said.
- Work with area schools. Get to know the faculty at your local nursing school or university nursing program. You might be able to arrange for students to do their internships at your practice, which may get them interested in staying once they graduate.
- Provide training. Give staff time off to attend training seminars-and cover the costs. Mr. Colaiuta said that it's important to invest in your technical staff not only for the good of the practice, but for staff morale.
Advertise strategically. If you plan to run a classified ad, time it to appear near graduation dates. Better yet, take advantage of job fairs sponsored by insurance companies, newspapers and radio stations that coincide with winter and spring graduations.
And don't forget to use word of mouth. Your nurses will spread the word to friends who are complaining about long hospital hours, who are tired of pushing paper at insurance companies or looking to leave other practices. (Consultants warn that actively recruiting nurses from other practices can harm your relationships with peers.)
- Create a pool of nurses. About five years ago, Summit Medical Associates in Hermitage, Tenn., created a three-person pool of nurses and medical assistants interested in working when the practice was shorthanded. One of the nurses had left the profession to have a baby, and one had retired. "It's saved us in many pinches," explained administrator Patricia Brown.
Treat your staff well. Robyn J. Levy, MD, a solo allergist in Atlanta, gives paid days off to top performers, and for each staff member's birthday, she pays for a massage or facial and gives them a day off. For Christmas a few years ago, she took her staff to a spa for a manicure, facial, massage and lunch.
"It's important to keep people happy and feeling appreciated," Dr. Levy said. "Every day when I send staff home, I thank them for coming. I don't just say 'Goodnight.' I say, 'Thanks for your hard work today.' "
Internist Archives Quick Links
ACP Clinical Shorts
Expert Education on Your Schedule
Short videos deliver highly focused answers to challenging clinical situations seen in practice and are a terrific way to earn CME credit on-the-go. See more.
New: Free Modules from ACP Practice Advisor!
Keep your practice moving in the right direction. ACP Practice Advisor is offering four modules that you and your staff can try for free. Get to know the premier online practice management tool at no risk. Explore the modules.