Gone are the days when you could recognize a nurse by her white cap and neatly pleated dress. Today nursing garb runs from colorful scrubs to business suits, and nurses' roles in modern health care are just as varied, going far past the bedside into the corporate boardroom and beyond.

# But whatever their job or garb, all nurses share a challenge: They don't have the numbers to meet the needs of all their patients.

A nursing shortage started in the late 1990s as a result of a rising demand for health care, changes in health care as a business, and the industrialized world's aging demographic. It's a global phenomenon, but it's particularly critical in San Luis Obispo and Santa Barbara counties.

"It's an acute problem nationally, it's an acute problem throughout the state, and I think it's especially acute on the Central Coast," said French Hospital President/CEO Alan Iftiniuk.

In 2004, the most recent state Board of Registered Nursing survey found that 10.6 percent of nurses in California said they plan to retire soon. The average age of the nurses was 48, compared to 45 in 1997.

Currently, there are about 230,000 registered nurses working in California. A 2006 study by UC San Francisco estimated that the state already faces a shortfall of about 16,700 registered nurses and expects that number to grow to 89,000 by 2030.

As Iftiniuk acknowledged, the situation on the Central Coast appears to be even more dire there are fewer new RN grads here than in other areas, the cost of living keeps people from moving here, and the demographic is older. The nursing workforce will need to grow by a full 25 percent by 2030 to keep up with the demands an aging populace will put on the health care system, according to the UCSF report.

But these statistics are more than just demographic trends coming neatly together on paper. This country has experienced cyclical nursing shortages before, the last of which was in the 1980s. But this most recent shortage's genesis is unique in its relation to the advent of managed care in the early to mid-1990s.

# "In the 1990s, how insurance companies and other providers paid for care impacted the ability of hospitals to do business the same way so they had to look at ways to make the operation more efficient," said Nicki Edwards, former chief nursing officer and present director of quality and risk management at Sierra Vista Regional Medical Center. She worked at a different Tenet hospital at the time.

Looking to cut costs, partly in order to please HMO insurance companies, hospitals across the country stopped raising nurses' wages, laid off nurses, left nursing positions unfilled as vacancies arose, or replaced nurses with unlicensed workers. At the same time that patient hospital stays began to shorten and the acuity of patients rose, the number of patients that nurses were asked to care for increased.

"The people who were left over after all the lay-offs were completely overworked and underpaid, and so a lot of people were leaving the profession, and nobody was going to school," said Jill Furillo, Southern California director of the California Nurses Association, the largest nurses union in the nation.

 

In one of the studies that would be used to argue for nurse-patient ratios, the Institute for Health and Socio-Economic Policy, commissioned by the California Nurses Association, found that the average number of patients under one nurse's care in California rose by 8.8 percent between 1994 and 1998. In that same year, there were only 2.3 nurses per 1,000 people statewide, giving California the second lowest nurse-per-population ratio in the nation. Washington state had the lowest.

The California Nurses Association used these figures and a body of research linking the quality of patient care and nurse staffing levels to argue for the nurse-patient ratios, signed into law by then-Gov. Gray Davis in 1999 and fully enacted in hospitals in 2005. The law requires acute-care settings to maintain nurse-patient ratios from 1:6 to 1:1, depending the acuity of the patient.

"I've been in nursing a long time and we've had more than one nursing shortage and it's kind of a cyclical thing," said Holly Stromburg, nursing program director at Allan Hancock College who's worked at Marian Medical Center since 1975. "The difference with this time around is all the Baby Boomers, and they're all going to retire at the same time."

National and state campaigns to lure people to the nursing profession and rising wages seem to be working. Interest in nursing may never have been higher.

But it doesn't matter how many people are ready to grab a stethoscope and get to work if they can't get into a nursing program and start studying.

 

So many options, not enough graduates
Nicki Couch, 24, and Cami Craig, 27, have very similar stories. Both moved from other areas in California to attend Cal Poly, initially majored in a health-related field, and then realized that the combination of hard science and direct patient care in nursing appealed to them. They both knew nursing school would be a lot of work. Neither understood the world of options that awaited them on the other side.

# "I didn't know nurses were paid so well. I didn't know they were in such high demand," said Craig, who just took a job in French Hospital's emergency room. "It's a different time for nurses than it used to be."

Craig and Couch recently graduated from Cuesta College's registered nurse program, along with 48 other future RNs the largest class that's ever passed through the school. The community college also just graduated its first group of licensed vocational nurses. Hancock College's registered nursing program has also grown in recent years. Both schools were able to add new faculty thanks to financial support from area hospitals.

Marian Medical Center gave $210,000 to Hancock College in 2006 and 2007, said Amy Silva, Marian communications specialist.

In San Luis Obispo County, Marian, Arroyo Grande, French, Sierra Vista, Twin Cities, and Mee Memorial hospitals contributed $15,000 each last year and this year to Cuesta College.

Yet the growth of the programs is hardly enough to meet the staffing needs of local hospitals, nursing homes, home health-care companies, and state and county agencies.

The number of students graduating from nursing programs statewide jumped from 5,178 to 7,523 between 2001 and 2006, according to the state Board of Registered Nursing. But at the same time, the number of applications rejected by schools jumped by an even greater number from about 4,000 in the 2000-2001 school year to about 17,500 in 2005-2006.

The situation is even more extreme on the Central Coast. Only 149 students graduated from an RN program between San Benito County and Santa Barbara County in 2005, according to the UCSF report.

Likewise, reasons for stunted growth at colleges are simply more pronounced on the Central Coast: funding limitations, a shortage of qualified faculty, limits of facility space, and limits of clinical spots at area hospitals. Both Hancock and Cuesta deans say that their respective programs have hit maximum capacity for the moment based on these limitations.

The nursing shortage phenomenon is full of ironies. There's only one on-site bachelor's-level nursing program on the Central Coast (at CSU Channel Islands) and no master's-level programs, and thus very few master's-prepared nurses to teach the next batch.

And even once a school finds nurses who have the education, a salary cut is likely in order. A nurse with five years of experience and a master's degree could make close to the triple digits in an acute-care setting. At a local community college, that number drops into the $50,000s.

"It can be very difficult," said Anna Davies, Cuesta's dean of student learning, sciences, mathematics, and nursing/allied health. "Where a full-time biology faculty position may draw 35 applications, an RN pool typically in the last three years has drawn one or two applicants."

Colleges also struggle to find enough space in local hospitals and other health-care settings where students can get the practical, hands-on experience they need to graduate.

"The reality is, yes, we can train more students in the classroom we don't have the ability to train them in the hospital. We've added as many [students] as we can safely add," Hancock nursing program director Stromburg said.

In an effort to confront these challenges head on, in April Cuesta placed a moratorium on its RN program wait list, which already stands at 286 students. Creative solutions may include merit-based or residency requirements for admission and looking in less likely places like King City for clinical space, Davies said.

According to the Board of Registered Nursing Annual School Report, 15.5 percent of nursing school students didn't graduate and only 75 percent graduated on time in 2006.

"That's an ongoing point of concern," said Joanne Spetz, co-author of the UCSF report. "You want to have the number closer to 100 percent graduating on time. Right now the numbers are looking pretty bad."

The State Assembly passed a bill in May to require community colleges to take the kind of action both Hancock and Cuesta are considering and make the selection process for RN programs more competitive to reduce attrition rates.

 

Recruitment is central
Of course, community colleges could graduate 1,000 students every year and it wouldn't make a pinch of difference when it comes to the bedside if none of those students stayed in the area. That brings us back to Craig and Couch, the Cuesta grads whose life stories have looked so similar up until now.

Taking a break before attending her commencement rehearsal, Couch managed to appear composed and confident even while wearing sweat pants and a pony tail it was easy to imagine her in her new position as a nurse in an intensive care unit at Stanford University Medical Center.

"I love this area, so it's going to be hard to leave. But I don't have family here now, and the hospitals are great but they're small hospitals," Couch said.

She'll be making $40 an hour in Palo Alto, far more than she could expect to make on the Central Coast as a starting nurse, though she said money wasn't what convinced her to leave.

"You're limited in what you see here because it's a small town, so the reputation that teaching hospitals have was a big draw for me," she said.

Craig's commitment to the area and her attachment to French Hospital were strong enough that she decided she can more than survive on the $25 to $28 an hour she expects to earn at French, though she doesn't know if it will always be enough, especially if she wants to buy a house.

In general, nurses in acute-care settings in urban areas like the Bay Area can expect to earn about $10 an hour more than nurses on the Central Coast, despite this area's high cost of living.

And despite the potential for more earning power elsewhere, many students do choose to stay in the area. Davies said she believes the majority of the Cuesta graduating class took a local job. Twenty-six of Hancock's most recent class members took a job at Marian.

"Our primary focus is here locally because what we have found is that the people who are from here and go to school here tend to stay here," said Kerin Mase, Marian's vice-president of patient care services.

Hospitals aggressively recruit students by offering them scholarships, promising on-the-job training, and actually paying them to finish school if they make a commitment to work at the hospital during their schooling and after they graduate, which Craig did with French.

This effort to "grow their own" staff stems in part from how difficult it is to recruit from outside of the area. Wage differences start to matter a lot more when you add on a trailing spouse. Many nurses have husbands or wives who are also very skilled, but who can't find local opportunities in their career field.

Sierra Vista currently has 19 open RN positions, but those that require more expertise or supervisory experience could take nine to 12 months to fill, Edwards said.

Whether or not there are enough qualified applicants for a position, hospitals are compelled by the nurse-patient legislation ratio, regulated by the state Department of Human Services, to keep floors staffed day and night.

"Given that there really aren't enough nurses to achieve that goal all the time, sometimes we have to turn away patients," Edwards said.

Specifically, Edwards said that if a hospital can't locate enough nurses, certain hospital visits, such as elective surgeries, may be postponed.

To fill in the gap, hospitals turn to traveling nurses who serve temporary stints in hospitals across the country and sometimes the world in exchange for the opportunity to live in new places, earn high wages, and sometimes even visas to work in the United States.

"Traveling nurses play a role, but the issues are typically we have less control of the quality and the training and they're less dedicated to the area, and frankly they're more expensive," French's Iftiniuk said. "Local nurses just have more passion and commitment to an area than someone who's just passing through."

Sometimes traveling nurses grow to love the area so much that the exact opposite occurs. Emma Edwards, RN, is an example. Coming from England six years ago as a traveling nurse allowed her to get her work visa. She worked temporarily at Sierra Vista before deciding to make the Central Coast her family's permanent home.

"When it became apparent that I wouldn't be able to stay a traveler much longer, it was kind of like, 'Why would we ever want to leave? This is such a perfect place,'" the nurse said.

 

Retention next
In health-care lingo today, "recruitment" is always uttered alongside "retention."

"We're committed to providing or taking the time to make sure nurses feel good about what they're doing, and feel good about the profession," Mase said of Marian's retention efforts.

In an area where more nurses in hospitals are either nearing retirement or fresh out of nursing school, Leslie Neely-Smith of Morro Bay is something of a rare commodity. She's a 39-year-old registered nurse with 15 years of acute-care experience, at least another 15 in her future, and a real love of patient care.

But last year Neely-Smith left the bedside at a local hospital to go to work at the California Men's Colony in San Luis Obispo. Her decision was based on a number of complicated factors.

Faced with the same nurse shortage that hospitals are, last October the federal receiver charged with improving health care in prisons obtained a waiver from a federal court to raise wages for medical staff. The salary scale of registered nurses at state prisons is now between $84,500 and $97,800.

As a result of the wage hikes, local hospitals say they're having to compete with state agencies for qualified applicants.

French's Iftiniuk said the hike in wages amounts to unfair competition because local hospitals can't compete with the deep pockets of a state agency like the Department of Corrections and Rehabilitation. He's written letters to the governor and local representatives saying as much.

Neely-Smith considered wages and benefits when she decided to take her job at the prison, but she said mostly she was seeking a different working environment.

"I would attribute the amount of work, the poor wages, and the focus on profit to the detriment of the patient. If you got into the field because you want to care for people, it hurts you to see that," Neely-Smith said. "I got tired of having to fight, fight, fight just to get what I needed to do my job."

Specifically, Neely-Smith left when she found out at that the hospital would be cutting some nurse-assistant positions, right around the time nurse-patient ratios were going into effect.

Though Sierra Vista's Edwards said the hospital only eliminated positions in the hospital's step-down unit and has since rehired nurse assistants, Neely-Smith's story illustrates the way nurses' perception of working conditions and comparative wages and benefits plays into decisions about where to work and whether to stay in the profession.

Neely-Smith says she loves nursing, but before the nurse-patient ratios went into effect, she was seriously considering going back to school to become a teacher. A high patient load on the medical-surgery unit meant she often felt like she couldn't respond to patients fast enough and left her questioning at the end of her shifts whether her patients had received proper treatment. She feared that the loss of nursing assistants would lead to similar circumstances.

According to the 2004 Board of Registered Nursing survey, there are about 7,000 nurses with RN licenses working in a non-nursing field in California, many of whom said they left because of dissatisfaction with the profession.

"To the extent that employers such as hospitals make nursing a more attractive profession, they may entice many of these people back to direct patient care," reads a Legislative Analyst Office report.

But staffing levels are just one element that contributes to working environments, a subjective area unlike wages. Emma Edwards chose Sierra Vista because of the working environment, specifically the relationships managers nurture with their employees.

"I've worked at other facilities, but you know Sierra Vista, I can't say enough good about the facility," she said.

Much of the working environment is determined by larger trends and changes in health care. Thanks to technology and advances in medicine, patients are living longer than they used to, often despite illnesses and chronic health problems. But these kinds of patients need more nursing care.

Also partly thanks to advances in medicine, patients are staying in hospitals for shorter visits, but that can create more work for nurses because intake and discharge paperwork are time intensive. The American Hospital Association estimates that for every hour spent on a patient in emergency rooms, nurses must spend another hour on paperwork.

"No one wants to frighten patients that they won't get cared for. They will get cared for," Hancock's Stromburg said. "It just might not be as personal and as nice as they'd like to have it.

"Where it hits the most, you don't have enough time to spend with individual patients, and that's where job satisfaction comes from the ability to interact with the patients," she continued. "And when all you have time to do is the real basic stuff, it isn't fun."

Luckily, as evidenced by the growing interest in the nursing profession, the current changes in health-care environments aren't scaring away too many able and willing patient advocates. Whether it's the evolving partnerships between hospitals and community colleges or new efforts by lawmakers, there's no limit to creative thinkers puzzling out some kind of solution to the nursing shortage.

"The more people become educated about this issue, the more they see that we're really on a slippery slope in California," Cuesta's Davies said. "So I think it's important that we're educating all the people that we can and lobbying our legislators to make a difference in this."

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Kirsten Flagg is editor of New Times' sister paper, the Santa Maria Sun. Contact her at [email protected].