Cost pressures lead to worst-ever nursing shortage, tough choices

Issue: March 2005

ByDouglas W. Jackson, MD

From the minutes of our recent departmental meeting: “Again concerns were expressed regarding the continued lack of available and experienced operating room staff."

Douglas W. Jackson, MD [photo] --- Douglas W. Jackson, Chief Medical Editor

In this month’s column I want to discuss, the ongoing orthopedic nursing shortage in operating rooms and surgical aftercare in the institution where I work. The impact on patient care related to the nursing shortage has occupied more and more of my time over the past two years. It has led to frequent discussions with our hospital and nursing administration.

Yes, over the years the pendulum has had swings related to nurse availability. But today’s shortage is the most difficult I’ve ever seen at our hospital.

What makes this so frustrating to me is that I spent the first two-thirds of my orthopedic career working with the same nursing leadership and nurses to continually improve surgical excellence in our operating suites and aftercare. During those years we had programs to enhance the training and expertise of operating room and ward nurses and technicians. In addition, we had a proficient support staff for operating and maintaining our advanced equipment to a high standard.

Struggling to keep up

Back then our efforts aimed steadily at improving patient care. Today we struggle to keep from falling behind.

In hindsight the problems really began around 1994, when reimbursements to hospitals and providers started declining annually. My hospital tried to offset this squeeze on margins by making it up in volume, expanding medical (including orthopedic) contracting for services. This brought with it a new group of physicians to provide the additional care, bringing their demands on our department. Ever since, my individual efforts in our institution have been primarily to do whatever I could in our department to hold the status quo. This has meant less time improving services and much more time trying to keep from slipping backwards in quality of support staff, equipment maintenance and capital flow for new equipment. While this experience may be more acute in Southern California then elsewhere, much of it will eventually impact you.

Today we are trying to do the same work, not just with fewer financial resources, but with fewer orthopedic operating room nurses and technicians too. This roll back extends to the sterile processing department and the staff epidemiological surveillance.

OR ratios fall

“Today we are trying to do the same work, not just with fewer financial resources, but with fewer orthopedic operating room nurses.”

Around the time reimbursements began to fall off in the 1990s we had 22 highly trained and dedicated orthopedic operating room nurses to staff our five orthopedic surgical suites. We now have the equivalent of 10.4 full-time professionals on our dedicated orthopedic staff. At times they cover six rooms (5.4 RNs and five technicians). What’s more, these same individuals provide a dedicated orthopedic call on the weekends and nights, stretching things even further. When we can’t staff our rooms with our dedicated personnel, outsourcing fills the gap. Traveling nurses are excellent, but they are expensive and must spend time learning our systems.

During this same period of nursing and financial shortages, we’ve been hit by two more big changes. One of these is that our nurses and technicians became unionized, adding new financial and administrative challenges.

Outpatient surgery challenge

The other change is that we face an aggressive new competitor in outpatient surgery centers, which threaten hospital-based orthopedic programs in many ways, most notably the following:

They have structural advantages that make them inherently more profitable and cost-competitive.
They draw away many patients and recruit the surgeons in our institution. More surgeons are building or acquiring interests in competitor surgery centers that filter off the better-insured patients.
They hire away our highly trained professional OR nursing and technical staff.

On a related article (Orthopedics Today, March 2005, page 72) we discuss staff shortages from the perspective of two of the OR nurses I work with in our institution. They are motivated, hard-working individuals who have always put the patient first. We must keep them — and other technicians working closely with them — in our system. That means addressing some of their needs as well as the needs of our surgical suites to provide the level of care we want to our patients.

The good news is that by working with all those involved in orthopedic patient care, I’ve have seen more positive changes since July 2004 then I have at any time during last four years. We are all working to keep this trend going.

We have filled a few new positions recently by hiring orthopedic nurses and our institution has begun a nursing-education program in conjunction with local academic centers to help student nurses obtain their nursing degrees and then come to work in our institution. There has also been some capital made available for new equipment from non-patient revenue sources and we have improved maintenance of the operating rooms and epidemiological support.

It will never be like the days where I used to have two orthopedic surgical scrubs on my big cases and financial resources were always available for the latest equipment. We have to be more efficient with all our resources today, work closely together, hopefully limit the consequences of cutbacks and not slide backwards.

Editor’s note: Please see Orthopedics Today, March 2005, page 72 (Management solutions for combatting workforce shortages) for a comprehensive article on specific short- and long-term steps you can take to combat the nursing shortage.