A survey conducted by AMN Health Care indicates deep career dissatisfaction among nurses, particularly RNs. The figures are pretty startling, and as AMN points out, the survey was conducted in a deep recession.

This survey comes from an agency that has a direct interest in this information. AMN is an industry staffing service, so it’s not good news for anybody in the sector.

This information should be a wake up call for the health care industry. AMN surveyed 1399 people. Looking at career intentions is a good survey methodology, because it reflects directly on the baseline position of the people surveyed.

The results are startling, and even allowing for sample deviations, the numbers should send a chill to health care staffing professionals:

Almost nobody believes the nursing shortage will be addressed by health care reforms.

29 percent of nurses are considering options that will either reduce their role or take them out of nursing. That’s a gigantic number of people. If 29 percent of nurses reduced their hours by one shift a week, that’s 729,453 shifts less per week, according to Bureau of Labor stats for total numbers of US registered nurses employed in December 2008, which was 2,618,700. That’s 39.49 million shifts per year. That would cripple the entire sector.

AMN makes the point that these views are influenced by current jobs, but in career terms only 59 percent would still choose nursing as a career. Not a good advertisement for the profession, and a clear indicator of how strong discontent is within the sector.

Six percent of nurses intend to retire in the coming year. That’s a very large number of people, well over the average attrition rate (AMN says this means 70,000 nurses, but it looks like they mean California only. Against the U.S. total, it could be 157,000, based on BLS figures). Current intake of new nurses would have a very hard time trying to keep up with that rate of loss, let alone cover the anticipated shortage of 26o,000 nurses expected by 2025.

As a benchmark, the survey raises some serious questions thatl need to be answered very soon. This isn’t the sort of problem that shows up as a glitch on stats and goes away. If these numbers are even half right, the sector is about to be hit by a 10 on the Richter scale of problems. There’s simply nothing there in the domestic employment market to absorb these losses. Even massive intake of foreign nurses would be playing catch up with the shortages.

Questions like these:

1. What’s being done about staff retention?
2. What’s required to enhance career satisfaction for nurses?
3. Where are the nurses and their training facilities going to come from to replace staff losses and meet demand?
4. Are there any realistic proposals or theories for covering lost hours or job loss for the 29 percent who are looking to change their roles?

AMN has done the sector’s work for it. The barely credible conceptual broomstick holding up the dilapidated old health sector shack can take only so much. This situation needs a holistic sector wide approach, covering all aspects of demand, or the whole mess falls over.

Stephen F. Austin State University in Nacogdoches, Texas has a new wing, the Richard and Lucille DeWitt School of Nursing, which houses a new approach to nursing training. The idea is a practical simulated treatment situation, using a highly advanced mannequin that can be adapted to any medical situation.

As all experienced nurses know too well, the job is very much about situations. Situational awareness and adaptation is a big part of nursing, and the new hospital is a lab where really any situation can be simulated.

The eternal sledgehammer of nursing experience is a major training aid. But the initial gap between training and real life in nursing has had to be bridged. A lot of time has to be put into learning how to deal with sudden exposure to quite literally anything and everything.

This is an extremely interesting idea, and it’s also a good practical development of a lot of ideas about nurse training which have been percolating through the sector for quite a while. People have been trying to develop a working system that can cover the whole gamut of training issues. The problem has been realism, and this new lab has apparently hit the mark. Students are confronted with difficult, often unnerving conditions, including gunshot wounds, gushing blood, a simulated patient who talks, and other sights and sounds of nursing.

Anyone who’s ever trained anyone to do anything will know that a critical part of it is teaching people to the point where they can think on their feet. That applies in multiples to nursing, where hitting the ground running at the first second of a case is the name of the game in so many different ways.

This mannequin can have a cold. It can go through ER from the ambulance stage through the entire treatment process. The general reaction to the concept has been so good people are calling it “creepy.” Life-like actions from the mannequin are generating a real set of responses and associations, which is a great sign.

Orientation and focus are also major elements in training. The development of a “Situation: Deal with it” approach is a very practical step. This setup provides an orientation where students can come to grips with procedures, problems and the information issues systematically, and focus on handling situations.

Female and child mannequins are also coming, and it’s clear that the lab is generating much interest across the training sector. This could be the start of a new dynamic in nursing training, and the possibilities for development are exceptional.

It’s easy to see the expansion and specialization of the simulation into other areas, where the very high demands of medical situations can be fully explored. After all, how many things can be hooked up to a patient, and how many people can be involved in care? Advanced care scenarios can’t be far away, and the mannequin is definitely a contender for some very complex care and management studies.

Don’t be too surprised to find a new form of nursing, Nursing Engineer, coming on sometime soon.

Stating the obvious regarding U.S. health care has never been a guarantee of success, or even a sentient response, but it’ll be interesting to see how the industry reacts to this new Gallup poll conducted for the Robert Wood Johnson Foundation.

The poll, conducted among 1,500  industry leaders, academics, insurers, corporate and health heavyweights, was a novel, ambitious stab at defining the role nurses should have in health care quality.

The net result was that while the vast majority of those polled believed nurses should have a major level of input into all aspects of health care, and would have a positive impact on health care quality, most saw nurses having the least actual influence.

The slideshow which accompanies this report (PDF document) indicates an overwhelming vote of confidence in the ability of nurses to make a positive impact across the entire spectrum of health care. It also includes a list of perceived barriers to nursing input, which is a virtual indictment of the industry’s archaic culture, including:

1. Nurses aren’t decision makers
2. Doctors generate revenue
3. No single voice
4. No leadership options
5. No strategic vision
6. Education compared to doctors
7. Stereotypes
8. Media depiction

This is a litany of ignorance. As a diagnosis, it would be “senility” after considering the truthful side to these percieved barriers:

1. Nurses make decisions affecting health care every few minutes.
2. There wouldn’t be much revenue if the patients died through lack of care.
3. The single voice has been yelling its head off for decades, continuously, in every known medium of mass communication.
4. The leadership options are managerial science-speak for lack of proper organizational design. You can’t lead if you don’t have the job as a leader.
5. “No strategic vision” as a description can also be applied to the health care industry since approximately 1980. It’s called “sector myopia.”
6. An advance practice nurse acquires several degrees, over a decade’s training, and is in constant contact with the operational realities of any organization for which he/she works, which is another education.
7. Since when are stereotypes a basis for organizational input? Is a “token nurse” on a committee the vision, or a professional manager?
8. Are they saying the industry would like to see a nurse running a hospital on TV, before they try it themselves?

Excuse my jaded writer sensibilities, but what in the name of antique bedpans does this vision of a world long gone have to do with anything practical? Is this the considered reason for an industry dynamic that can’t even understand the basic functions of its own workforce? We’re talking about an entire industry engaged in saving people’s lives, not a script for All In The Family. I’m assuming Archie Bunker hasn’t moved on and up into health care. Health care by cliche and typecasting doesn’t look like the immediate rush to best practice the industry needs.

Removing the barriers, not surprisingly, is seen as the primary issue in giving nurses a more appropriate level of input. From the look of this assessment, it may require a few Flintstones remakes as training films, but it’s a start.

In the U.S., the first sign of the new reality, “See the World: Become a Nurse,” is already reshaping the whole concept of nursing. That is now a global phenomenon, as the strange, inverted form of musical chairs continues around the world with nursing numbers.

Nursing is now a demand-driven profession around the world:

• Surges in sector demands: Various areas of nursing, like geriatric, are experiencing ever-increasing demands as the Baby Boomers retire. This increase in demand will continue over the next 20 years.
• Remote area nursing: The shaky health budgets of remote areas are driving a demand for nurse practitioners.
• Advanced practice nursing: The demand for realignment of health care provision toward nurses is increasing as more advanced practice nurses enter the workforce as primary medical service providers.
• Demographic demands: Larger urban areas are acting as gravity wells in the employment market, demanding more nurses.
• Health care economics: High costs are causing a continual revamping of health care business models and demand for nurses to cover more territory in all types of health care facilities.
• Community health issues: A range of health conditions in the general public has placed a massive demand for health care on a system that can barely cope.
• Global aid: Recent major disasters and humanitarian aid have created a significant demand for trained nurses around the world, diverting nurses from their domestic roles.
• Epidemics: The ongoing series of major epidemics like AIDS, TB, and other significant diseases has added a major demographic burden to all forms of health care. Each case adds more demand as resources are diverted to deal with these persistent problems.
• Retirements: The retirement of experienced nurses is already creating a shortage in the U.S., displacing existing staff and leaving gaps at all levels.

The demand issues aren’t being handled too well:

Bureaucracy: In the U.S., where a shortage of 500,000 nurses is projected by 2025, bureaucracy is now creating a block to filling spaces. Visa problems, not health care, are preventing many Filipino nurses from filling jobs. Putting this into perspective, 55 percent of New York’s nurses are foreign born.

Training times and educational infrastructure: Meeting demand has become a huge priority, and colleges are finding it impossible to cover either the demand for places or the demand from industry. That’s a situation that can’t last.

Recognition of qualifications: Another routine stumbling block, where even Japan’s all embracing health care system is requiring additional examinations for foreign nurses. This is an entrenched, unintentional obstacle in all areas of health care, but in nursing it’s also a great way of ensuring demand is never met.

What’s needed is a holistic approach to the reality of globalized nursing:

1. A single stream, prioritized entry process for nurses, with a streamlined procedure, is comparatively easy to legislate.
2. More remote training systems must be implemented ASAP to meet the demand for places.
3. Standardized qualifications are required. The current system standardizes at the entry points, not at the points of qualification. That’s diverting training from the domestic demand, as well as slowing down bringing in new people.

The realities of nursing and the media image of nursing are moving steadily apart. TV nurses never have sore feet, and their main function seems to be simply wearing a uniform and standing in front of a camera, providing cues for TV doctors.

Nobody expects mass media to have much more of a clue about nursing than anything else it depicts, but the vague view of nurses and nursing is now starting to look like a neglected Model T at a Ferrari convention.

It’s fair to say that writers, producers and networks pay very little attention to  the heavy lifting work of nursing. That’s partly because the real work rarely fits the story lines, and the real dramas in nursing would be too much for broadcasting, even if the writers and producers understood them. A sanitized reality is about as close as they’re allowed to get. Media buyers won’t touch anything controversial or threatening, either, because of sponsorship.

The result is a Flintstones-like image of the profession. The archetypal nurse continues to be single, attractive, in her 20s or early 30s, with the occasional male nurse in a usually non-speaking role thrown in as an alternative form of conceptual furniture.

That particularly undemanding set of production values wouldn’t even have applied to nurses in the Civil War. The famous Dorothea Dix was 60, a martinet, a highly successful nursing manager, and tough as nails. Sally Louisa Tompkins, her Confederate equivalent, literally ran a hospital that only lost 73 people in nearly 4 years, a number that any modern hospital, even Walter Reed, would appreciate. That was in an era of primitive sanitation, endless amputations and no antibiotics, too.

However, Ken Burns, not the mass media, was the one who drew attention to their work. Anything important or inspiring about nursing can usually be found in history books, not current media coverage.

The general trivialization of nursing in the media is having a few notably counterproductive effects:

1. It devalues nurses in the eye of the public. They’re still being shown in minor roles, when in reality they spend more time with the patients than doctors, and do most of the hard work in keeping patients alive.
2. It misrepresents the role of nurses, particularly the advanced practice nurses now taking up the load of looking after America.
3. It’s providing a very sugary image of the profession, almost the exact opposite  sort of image needed to attract strongly motivated people.
4. The professional environment is misrepresented. It’s too simple, too straightforward. It’s a matter of opinion whether anyone but a top comedy writer with a very black sense of humor could accurately depict some basic real life story lines in which nurses find themselves playing roles.
5. The melodramatic elements are good TV, but lousy indicators of how nurses operate. Few have the time for theatrics, even on long shifts. Some dramatic situations in the entertainment industry wouldn’t get so much as a blink out of experienced nurses.

A virtual nurse called Elizabeth may be the start of a useful backup system for nurses dealing with discharged patients who are bedridden and need information. Elizabeth is an animated character working on a touch screen. She provides an FAQ-like system for medication, outpatient care, and other basic issues.

Elizabeth was introduced to assist with a problem that had been noted among outpatients regarding their information levels. Studies showed that the average outpatient received eight minutes of actual contact and advice from a nurse. This is not enough to cover all issues, obviously, and many outpatients don’t know what questions to ask. And since 20 percent of outpatients are readmitted within 30 days, there was an obvious need to improve the situation.

Elizabeth is a real character with facial expressions copied from doctors and nurses, a friendly interface with the information system. While she’s not designed to replace nurses, she can definitely fill in for them in certain areas. She gives information, then makes sure the patient understands by asking questions on the touch screen. If the patient gets a choice wrong, she lets them know and provides the correct answer. If Elizabeth can’t answer a preset question, she issues an alert.

Elizabeth may be a way to improve an issue that has dogged modern medicine for some time: Patient knowledge and understanding. The fact is that patients, who are by definition unwell or convalescent, can’t necessarily absorb verbal information very effectively. A “try again” approach where patients can check their information and make sure they get things right is definitely a good idea, allowing the patient to work at their own speed of comprehension.

The software is also highly adaptable. This sort of program can be modified considerably for specialist use, and is a definite plus in terms of providing a direct link with outpatients. This can act as an active and passive monitoring system as well, where even a lack of use of the software can be reported, in case the facility loses contact with the patient.

The hardware also works well. The touch screen system is easy to use, and touch screens tend to be pretty durable and reliable, able to stand any domestic environment. It is an easily portable format, not requiring a customized infrastructure to operate, although it would need to be easily rechargeable like a cell phone if battery operated, and have DC converter backup.

Elizabeth has one more valuable asset. Her information can be checked by nurses to make sure she’s up to date, and that the information on her system is correct. That’s something you can’t do with people.

Elizabeth could help save a lot of lives, and a lot of time for nurses. Don’t be surprised if she, or one of her descendants, shows up in your outpatient clinic soon.

If you’re an aspiring nurse, or a nurse having a difficult time pursuing advanced career development, distance learning may be the answer. Distance Learning U, better known for its other distance learning facilities, has created a special suite of online nursing programs. These courses are available through accredited nursing colleges like the University of Phoenix. The courses include Bachelor’s and Master’s degrees, and a considerable range of useful career development programs.

For intending nurses this may well be the answer to the current log jam of applications that has caused colleges to turn away 40,000 applicants this year. If so, distance learning could do the nursing profession a big favor by helping to overcome the shortage of nurses that the traditional college system has been unable to do effectively.

It’s becoming increasingly clear that online qualifications are the unavoidable way of the future. The old college system, which was originally designed to meet the needs of a much smaller demographic of applicants, can’t cope with the existing number of potential applicants, let alone another few years of them.

This is also a very functional approach to a nagging career issue for many trained nurses, particularly those who are only a qualification or so away from a major career upgrade. The same problems apply, finding places, but with the added strain of trying to do so with an ongoing job involving shifts, and fitting it in to a life and work routine that simply does not allow for traditional college studies.

The need is for a systemic form of training that:

1. Accurately reflects the range of roles in the modern nursing employment market.

2. Meets health sector demand.

3. Covers the rapidly diversifying needs across the health care sector for skills.

4. Is a practical study method for career advancement for those in the workforce, not a dislocating, expensive, “hiatus approach” to training.

The log jam at career entry point is also a symptom of a potential systemic failure. Advanced nurses, particularly nurse practitioners who are taking on much of the load of the current health care market, require a lot of training. It’s becoming very clear that if training systems aren’t up to speed with health sector demand, there will be a permanent shortfall in this vital area until they are.

Distance learning may be the only way to avoid this situation. If Distance Learning U and its associates can get those 40,000 hopeful nurses into the system and qualified to a baseline degree level, they’ll be doing the nation a lot of good by blazing a way forward.

One of the more interesting areas of career development for nurses is research. Currently, a lot of nursing research is focusing on core nursing issues, particularly community related issues.

Arguably the most prestigious nursing research facility in the world, Johns Hopkins is proving a point with its research: Few professions work in the community on the same level as nursing. Several of Johns Hopkins senior researchers have been applying nursing research to social justice, and the results have been spectacular, applying useful concepts across a broad spectrum.

Their work relates to the very tough social environments in which some of nursing’s most fundamental services are conducted. This is core nursing, in the heartland of the social wildernesses where so much community nursing is involved.

An interesting professional aspect is that as the nursing profession ramps up with advanced skills and education, the ability of nurses to conduct this very valuable work will be greatly enhanced. Also interesting is that many of the primary skills of fundamental nursing are also the primary characteristics of research practices. Observation, problem solving, accurate definition and analysis of issues, and the rest of a nurse’s daily menu of attributes are common factors.

The entire concept of nursing is undergoing a radical renovation, long overdue by the standards of the profession. The new horizons being created by the research functions in advanced nursing are likely to redesign the profession even further.

Nurse practitioners start their working careers, as specialists, literally on the cusp of the research environment. Medical science could be sitting on a potential goldmine of new research talent, if the culture embraces the idea of nursing as a science rather than an adjunct to medicine.

The Johns Hopkins research has proved another point - that research is in nurse territory, areas where normal clinical research usually wouldn’t go. It’s also the sort of work well suited to the nurse practitioner’s fundamental strengths, where their areas of expertise meld with their environments.

Nursing doesn’t have “boundaries.” Community health includes the social environment, clinical practice, and adapting to the needs of a particular environment. Much like the health care industry and the other medical professions, the need is to adapt to the realities of social environments. Nursing by nature is a holistic approach to care.

Nurses are everywhere in medicine, observing, refining and developing their professional concepts on a daily basis. Their experiences are encyclopedic in scope. If the health care industry is wise, it will do everything it can to promote nursing research and create good career development opportunities for nurses to do their research. The future is here. We just need to open the door and let it in.

Across the U.S., the muttering at local levels about nursing home and other institutional closures is rising to a roar. It’s so far been a turgid tale of budgets, funding issues, and Medicaid. But the subject has been thoroughly ducked by state authorities, and public comments by officials are noticeably absent. How is this possible?

Here is the more increasingly common situation: Some nice old soul whose main preoccupation has been trying to pay for medication has been told to leave, and the family, grappling with the recession, is running around trying to find a decent level of care. Meanwhile, silence. No information, no clarification.

In Buffalo, NY, a reader wrote to a local website asking why nobody was covering the story.

In New Jersey, 5 out of 7 institutional care facilities are threatened with closure as a result of a revamp of the state budget.

In Toledo, OH, the Arbors at Toledo nursing home has been sold as a purely business exercise. 120 workers will lose their jobs in March 2010.

In Tuscaloosa, AL, the main topic of conversation in the local news is an administrative appeal about the closure of the venerable Alice Kidd Nursing Home, which is described as the last in the state.

In Albany, NY, a new nursing home may only continue to be constructed if the 2010 budget goes through, after 109 layoffs at another facility.

The likely result of this national trend is a floating population of people across the country in need of care. The last thing on everyone’s mind, apparently, is having a source of support for those who need it. Years of failed economics are the primary reason for this culture. The basic concept of doing things properly in health care has vanished. This is the result.

This is looking very much like the traditional bad business model that is inevitable when people try to run important services like they are retail businesses. A nursing home is not a drug store, and it shouldn’t be operated like one. The bottom line has kept rising, thanks to the “user pays” approach, which has always been a recipe for increasing charges up and down any supply chain. The idea of sharing a cost load has vanished.

State budgets, which in medical terms have been on life support for decades, haven’t exactly been ideal for planned health care. If there’s no Federal money around, too bad. The resulting mass of dislocated people will therefore hit the rest of the health system, making surviving facilities harder to operate effectively. That could crash quite a few more homes and institutions because of the demand on costs.

This was once the most advanced, efficient health care system in the world. It now ranks behind just about every other Western country. Nowhere else in the English speaking world do health care professionals and the public have to tolerate these situations. The inexplicable, not to say inexcusable, lack of comment from top officials looks like the whole issue has been put in the too hard basket. It’s either maladministration or incompetence.

The nursing homes are experiencing business situations that first year management trainees are taught to avoid. There are no excuses. Nor is there any business logic to support the current mess. A few weeks ago we did a story on a very strong business model operated by Canada’s Nurse Next Door franchise which is having no trouble in this market, and is expanding like crazy. There’s no reason why nursing homes can’t be adapted to run on trustworthy operating principles like these. It’s time for those responsible to stop ducking issues and earn their highly paid jobs.

This is looking like Amateur Hour. “Disgrace” at this point, is a mild euphemism.

According to the American Association of Colleges of Nursing (AACN), 40,000 applicants were turned away in 2009 due to a lack of resources in the form of faculty shortages and clinical facility constraints.

Overall graduations increased by 3.5%, and Masters and Doctoral degrees increased significantly, by 9 and 10% respectively. This is nice, but these numbers alone don’t equate to a significant increase in the relative number of trained nurses after retirements are factored in.

The risk here is that many of those 40,000 hopefuls will be back next year and face the same problems, with a further increase in numbers as others join the queue. This could be the beginning of a log jam.

Arguably worse is the fact that these are motivated students, exactly the people the nursing profession needs. However, staying motivated isn’t going to be easy if this situation continues.

There are several problems here that aren’t going to go away unless the whole training paradigm is upgraded to modern employment market standards:

1. The demography of nursing in the U.S. currently contains large numbers of nurses who will be retiring in the next ten years, and taking their priceless experience with them. The knowledge gap is likely to be serious, without continuity.

2. Nursing practices have changed dramatically and advanced practice nurses, who are expected to become major components of health care services, need much more lead time to qualify.

3. The need for continuity in quality of nursing training applies on the job, as well as academically. Good nurses don’t just happen, they require a lot of this training and experience. Any shortage of skilled nurses is going to spill over into the workplace in various ways, none of them helpful to front line nursing.

4. This mechanism is exactly how skills shortages become problems. There is a need for thousands of nurses, but a training system that produces only hundreds. The training machinery is out of step with the market and the demand. Sprinkling a restricted number of nursing college graduates across America isn’t likely to improve the overall situation.

Some possible solutions:

1. There are many senior nurses with training experience who could be “drafted” by the colleges. The ratio of trainers to trainees could be made workable. This would also help pass on irreplaceable experience to a new generation of nurses.

2. Consideration should be given as to what can realistically be done off campus, to reduce direct pressure on faculties and resources. Some of the purely academic work could be done online. This would free up space and time, and an increased intake could be at least partially accommodated by online academic trainers. This approach works for most fields of study, but would have to be adapted to nursing college training requirements.

The other possible benefit is that it may reduce real costs to nursing colleges, freeing up instructors to at least some degree from number crunching onsite exercises. A real reduction in costs may also give the nursing colleges some working capital to do something about improving clinical facilities.

Let’s hope something happens, because the prognosis at this stage is dubious at best.