Special Commentary: Obamacare is Here to Stay, But What About the Nurses?

President Obama and Vice President Joe Biden in the Rose Garden (Getty Images)

With the Supreme Court ruling last week, the President announced definitively that the Affordable Care Act (ACA) is here to stay and advised that now is the time to get back to work. One aspect of “getting back to work” is ensuring that our health care system functions at its highest level as the ACA continues to do its job of providing access to care for millions of once uninsured and underinsured Americans. A critical hallmark of a functioning modern health care system is the reliable delivery of professional nursing care. What history shows is that the perplexing and enduring problem of nurse shortages have frequently left the nation’s health care system compromised.

Alexandra Robbins highlighted this issue in a recent New York Times op-ed article “We Need More Nurses,” which identified pockets of nurse understaffing around the country with an uptick in nurses reporting frustration and potentially dangerous situations for patient care. This, of course, is not a new situation. For most of the 20th century, the US witnessed profound and severe nurse shortages which imperiled patient care and created repeated crisis situations in our nation’s hospitals. The historical underpinnings of past nursing shortages offer a means to critically analyze and address nurse understaffing today.

History of Nursing Shortages in the US

Let’s take a look at one mid-20th century nurse shortage, which first appeared in the late 1930s and continued into the 1970s, as an example of how shortages appear and the type of solutions used to alleviate them. Ironically, the genesis of the 1930s shortage lay not in a shortage of nurses, but rather in what was labeled an oversupply of nurses.

During the 1920s, hospitals, relying on student nurses to deliver the majority of patient care, increased significantly the number of students they admitted into hospital-based nurse education programs. Each year more and more students graduated from these programs creating severe overcrowding in the nurse labor market. At the time, most nurses were not employed by hospitals but rather worked as private duty nurses hiring out as independent contractors to patients who paid them out of their pockets for care. But the number of patients able to afford private nursing care was limited, and as additional students graduated the situation deteriorated. The onset of the Great Depression exacerbated a serious state of affairs as the number of patients able to pay private nurses plummeted. Severe nurse unemployment followed with dire warnings that the country had produced too many nurses and needed to close schools.

Then, seemingly overnight, demand for nurses began rising. Several factors drove this demand, including increasingly complex patient care requirements which were the result of advances in medical treatment which forced hospitals to decrease reliance on student nurses in preference to fully educated experienced nurses. A depression era movement to spread the work available by reducing the number of hours each nurse worked from 12 to 8 increased the number of nurses who worked over a twenty-four-hour period led to additional jobs. Further, the rise of employer-based health insurance plans provided access to care for millions of Americans.

Hospitals reluctantly responded to the new demand for nurses by hiring more nurses, mostly on a per diem basis. This practice relieved hospitals of temporary nurse shortages but failed to provide a reliable workforce and aggravated nurses eager to find permanent employment.

The onset of World War II intensified the shortage. Approximately 25 percent of professional nurses joined the military, which led to a dearth of nurses to care for the civilian population at home. To deal with the shortage a massive federal financial aid program to nursing education, the Cadet Nurse Corps was designed to increase the nursing workforce. Hospitals also began extensive hiring of nursing assistants.

THUMBNAIL_PGH_mc13_bx16_0485The post-war era saw hospitals turning to the recruitment of foreign-educated graduate nurses. The number of nurses did rise as a result of these solutions, but not at levels to reach the demand. In addition, there continued to be a lack of commitment to improving working conditions for nurses. This was most apparent when comparing salaries paid to nurses, which lagged significantly behind other similarly educated professionals. For instance, a 1948 Department of Labor study, The Economic Status of the Registered Professional Nurses, 1946-47, blamed nurse shortages on the incredibly bad working conditions of low pay, difficult hours, few benefits, and a lack of inducements to draw people into the field. Eventually, the shortage abated, but not until the 1970s when several factors including improved salary levels made possible by better hospital reimbursement via the Medicare and Medicaid program made nursing a more financially attractive occupation.

Which leads us to the present day. As we contemplate the success of the ACA in reducing the number of uninsured, there is the sobering reality that demand for health care services will inevitably lead to another nurse shortage.

A critical hallmark of a functioning health care system is the reliable delivery of professional nursing care  - Jean C. Whelan

So what can we do to meet the demand for more nurses? Historically, solutions to nurse shortages tend to follow patterns typified by the 1930-1970s shortage and involve simply flooding the marketplace with more nurses. On the surface, this seems like a commonsense solution. After all, if you don’t have enough of something it makes sense to make more—don’t have enough nurses, just create more of them. Yet, increasing numbers without looking at nurses’ work situation is shortsighted. Robbins’s op-ed advised that hospitals treat nurses right. I echo that sentiment and suggest that hospitals consider the historical failures in adequately addressing shortages in the nursing workforce when devising new solutions. Our health care system needs more than just a large influx of new nurses. It needs to provide a working environment that supports nurse staffing adequate for patient safety while valuing nursing as central to a functioning and successful health care system.

The ACA is guaranteeing access to health care for millions of Americans. Let’s begin the arduous work of ensuring that access to sufficient nursing care is seen as a fundamental right.

Update

7/2/15: The Pennsylvania General Assembly published a study entitled “Professional Bedside Nursing: A Staff Study” that examines nurse staffing levels. The study touches on many of the themes described in this blog. In addition, the findings of the study provide 6 key recommendations on improving nurse staffing and patient outcomes. Read the full the text here.


Jean C. Whelan is a leading nurse historian, president of the American Association for the History of Nursing and the assistant director of the Barbara Bates Center for the Study of the History of Nursing Dr. Whelan’s research centers on the historical development of U.S. nursing workforce, the issues which shaped nursing’s development and the policy implications involved in maintaining adequate nurse services.

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