workload for nurses At issue: Professional burnout, training and retirements challenge nursing shortage

By JACK NISSEN
Special to the Journal
LANSING — Dawn Kettinger recalls a nurse who had just completed a 15-hour shift, got into her car to drive home and fell asleep before leaving the parking lot.
Imagine that same nurse working one more hour in an environment where patient care is top priority. She asks: How can someone be asked to work in lifesaving situations when they can barely stay awake at the end of their shift?
“It contributes to the loss of experienced nurses in the field,” said Kettinger, the government affairs director for the Michigan Nurses Association.
The national burnout rate for new nurses is high. About 17 percent leave within the first year and 33.5 percent leave within two years, reports the Robert Wood Johnson Foundation.
That’s costly for hospitals, harmful to patients and creates a shortage of nurses needed to replace retiring ones.
A manageable caseload during a nurse’s 12-hour shift is usually four patients, Kettinger said. But they often work mandatory overtime and care for six, seven and even eight patients at one time.
That workload risks patient safety and increases the already high burnout rate, pushing nurses to find work elsewhere, Kettinger said.
Some lawmakers are attempting to address the issue.
Rep. Jon Hoadley, D-Kalamazoo, has introduced a bill that would set caps on how many patients a nurse can have, depending on the unit they’re in. The bill, which has bipartisan support, also would prohibit a hospital from forcing a nurse to work longer than 12 straight hours.
“When it comes to taking care of your loved ones, that’s something everyone relates to,” Hoadley said. “We need champions in the Legislature who are willing to make sure we’re putting patients and nurses first.”
Some hospitals maintain safe numbers, Hoadley said. But it’s important that the Legislature establishes what is acceptable and safe for those that do not. Right now, there are no legal limits on a nurse’s patient load.
“We have a moral and ethical obligation to act, because … medical errors and staffing ratios have contributed to thousands of deaths or injuries,” Hoadley said.
While there is no way of knowing how many incidents are due to a lack of nurses, a 2014 Michigan Health Association report showed there were 52,000 incidents, near misses and unsafe conditions in Michigan hospitals.
State lawmakers have unsuccessfully tried to regulate nurse conditions in hospitals before. While not yet taking a formal position on the current legislation, the Michigan Health and Hospital Association has opposed similar bills.
“We believe that our local hospitals are best equipped to make the decisions in caring for their patients, and that includes staffing ratios,” said Laura Wotruba, the association’s director of public affairs. “Clinical care decisions shouldn’t be made in Lansing. They should be made in the local communities that take care of the people.”
The association is committed to working with nurses, but understands there is a burnout rate for new nurses when they enter the field, she said.
“Mandatory overtime is not the preferred option to staff a hospital, and they employ a number of different efforts to avoid that,” Wotruba said. “But it does happen because we’re caring for people around the clock.”
To address the stressful environment of hospitals, the association’s solution to burnout isn’t more nurses, but more training and education. Several studies show that training, not more nurses, improve patient care, Wotruba said.
Randolph Rasch, dean of the Michigan State University College of Nursing, agrees. While an increase in nursing staff does improve the patient outcome, the level of education is a key indicator, he said.
“One of the consistent things is that in those institutions that consistently had better outcome for patients, there was a higher percentage of nurses prepared with a bachelor’s degree,” Rasch said.
An outcome of such studies by the Center for Health Outcomes and Policy Research at the University of Pennsylvania is the Magnet program, a gold standard awarded to hospitals that meet high standards for nurses. To be eligible, 75 percent of a hospital’s nurses must have a baccalaureate degree.
Michigan has 12 Magnet hospitals. While there’s no way of knowing how many are also pursuing the status, Kettinger says it’s becoming a barrier for students wanting to work as nurses.
“It’s a marketing ploy,” she said. “Hospitals brag about the status, but it doesn’t mean they have safe patient-to-nurse ratios.”
To become a registered nurse, individuals have to pass a test. It can be taken by people with associate or bachelor’s degrees in nursing. Kettinger worries the push by hospitals to become Magnet programs is making two-year programs offered at many community colleges less attractive, even though they are a more cost-effective route to becoming a nurse.
“We reject the premise a bachelor’s degree is required and preferred to be a bedside nurse,” she said.
The shift in preference for bachelor’s degrees is also impacting current nurses, who may have years of experience under their belt but only two-year degrees.
“We already have nurses with all the right education,” said Rep. Roger Hauck, R-Mount Pleasant, and a supporter of the bill. “The problem is we’re going to have a shortage of nurses by requiring them to go for four years instead of two.”
Hauck’s daughter is a nurse with a BSN and his wife is a nurse with an associate degree, he said. The hospital is making his wife go back to school.
Worried a nursing degree from two-year programs could become useless, the Michigan Community College Association based in Lansing has supported past legislation to allow its members to administer four-year nursing degrees.
“If there is a nursing shortage, it would make sense to remove the number of barriers to get more hired,” said Mike Hansen, the group’s president. “You don’t want to jeopardize professional standards. However, if there are more technical or bureaucratic laws keeping people from getting hired, then why wouldn’t you make it easier?”
But the Michigan Association of State Universities, based in Lansing, whose members provide those four-year degrees, says there are already enough programs to accommodate the nursing shortage.
“Whether it’s the BSN degree in nursing or any other occupation, we believe community colleges offering a four-year degree would represent mass duplication of those programs and enormous inefficiency of taxpayer dollars,” said Daniel Hurley, the association’s chief executive officer.
In a state already facing a decline in high school graduates, it makes little sense for community colleges to offer four-year degrees, he said.
But Rasch said the extra two years in the BSN program helps raise the level of competency for a nurse. It prepares them for the complexity of care now necessary in the field.
The bill would also mandate that hospitals make their staffing ratios public. Right now, they aren’t obligated to release that information.
“Some hospitals are saying ‘we’ve got this, trust us, but we don’t want to prove to you we’re doing things correctly,” Hoadley said. “When someone gets sick or there is an accident, you don’t know how many people are working.”
Much of Hoadley’s bill is based on a 2004 California law. It resulted in nurses caring for one less patient than nurses in other states, a significantly lower mortality rate and a higher level of job satisfaction, according to a study of 225,000 California nurses by the Center for Health Outcomes and Policy Research.
But even if the burnout rate falls, Michigan needs yet more nurses to replace those who are retiring. More than 40 percent of the state’s registered nurses are 55 or older, according to 2017 data collected by the Michigan Annual Nurse Survey Project. Most will retire within the next 10 years
“Right now, we have a large number of our nursing workforce that have reached 65,” said Carole Stacy, the Michigan League for Nursing president. “They are retiring in hefty numbers and we’re losing a big brain trust.”