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- George A Beller, MD, FACC*
- ↵*Reprint requests and correspondence: George Beller, MD, FACC, Cardiovascular Division, Department of Internal Medicine, Health System, University of Virginia, P.O. Box 800158, Health Sciences Center, Charlottesville, Virginia 22908-0158
Teamwork is absolutely essential to the practice of cardiovascular medicine and its subspecialty disciplines. To achieve optimal patient care and patient satisfaction, there must be collaborative efforts in both in- and outpatient settings as well as in the clinical laboratories. When physicians, nurses, technicians, and allied health professionals collaborate, everyone is more effective—and patients reap the benefits.
The vital role of nurses in the delivery of cardiovascular care
Having an adequate number of well-trained and dedicated nurses in all of the practice settings is crucial to the delivery of high-quality care and good patient outcomes. Since the 1990s, cardiovascular specialists have increasingly relied on the availability of nurse practitioners and advance practice nurses with whom to work closely and to provide comprehensive cardiovascular care. These and other nurses play a major role in gathering information from patients during first encounters; implementing patient-management protocols; conducting patient education; monitoring and dosing certain therapies, such as warfarin anticoagulation; adjusting doses of other drugs, such as lipid-lowering medications; and following up with patients in their homes or via telephone. Involving nurses in this type of team approach to patient care has been successful; for example, in heart failure management, using teams has resulted in fewer hospital admissions and better treatment outcomes. Advance practice nurses or nurse practitioners on heart failure services are often responsible for the outpatient titration of drugs like carvedilol and diuretics between patient visits. Such nurses carefully monitor symptoms and body weight after each titration, which is particularly important with carvedilol because patients might initially have worsening heart failure symptoms with initiation of the first dose of the drug.
The other ways in which nurses participate in cardiovascular care are numerous. Many nurses are engaged in enrolling patients in clinical trials and following these patients throughout the research protocols. Without the active involvement of nurses in these endeavors and their responsibility in overseeing these studies, clinical investigators would find it difficult to carry out multicenter trials so effectively. In many teaching hospitals, nurse practitioners and advance practice nurses have taken the place of medical house staff on short-stay cardiology inpatient units (i.e., 23-h stays for patients undergoing diagnostic catheterization). Nurses play integral parts in heart failure/transplant services; electrophysiology, pacemaker, and stress testing laboratories; chest pain units; and interventional programs based in catheterization laboratories. In recent years, their roles in preventive and rehabilitative activities have increased markedly.
The role of allied health professionals in cardiovascular care
The allied health professionals who provide technical support for our clinical laboratories also are indispensable for the delivery of cardiovascular diagnosis and therapeutic services. What would physicians do, for example, without electrocardiography and echocardiography technicians, catheterization laboratory technicians, and nuclear cardiology technologists? Not only do they perform the tests physicians rely on for timely diagnostic information, but they also are often the first individuals a patient encounters in the office setting or after registering at the hospital. Often, by making a patient feel comfortable and taking the time to assuage the anxieties of the patient and his or her family, these professionals greatly enhance all aspects of the health care experience, including patient satisfaction. Like nurses, allied health professionals are often the individuals whom patients cite even more often than their physicians when describing why an experience with a particular cardiology service was positive.
Many others, such as hospital pharmacists, dietitians, and social workers, have become part of the team approach we now accept as necessary for outstanding care, continuous quality improvement, and favorable outcomes for patients with the acute and chronic diseases that cardiovascular specialists manage.
Shortage of nurses
The highly sophisticated U.S. cardiovascular system, which utilizes the talents and skills of so many of the health professionals previously mentioned, is in jeopardy in many parts of the country because of another nursing shortage and a shortage of allied health professionals. The Department of Health and Human Services predicts that, by 2005, the U.S. will be lacking about 200,000 advanced practice nurses (1). One study (2) indicated that for California to maintain a stable ratio of registered nurses for its population, an additional 43,000 nurses will be needed by 2010 and another 74,000 will be needed by 2020.
The Bureau of Labor Statistics has projected that, through 2006, positions for registered nurses will increase substantially more rapidly than will average employment growth. Job opportunities in nursing will increase by 21% compared to 14% for all occupations (3). According to government statistics, by 2015, approximately 14,000 full-time equivalent registered nurse positions will be unfilled nationally.
In the meantime, the population is aging, and the prevalence of chronic cardiovascular disease is projected to increase by 66% in the first 30 years of the new millennium (4). As the “baby boomers” age, the demand for health care will increase substantially, and a nursing shortage will surely have an adverse effect on the ability of the health care system to care for this aging population with its concomitant chronic disease. Already, new nursing positions have emerged in outpatient settings (e.g., home health, long-term care, outpatient ambulatory surgical centers, managed care settings, outpatient cardiovascular medicine clinics). Within the hospital inpatient environment, the nursing shortage is most prominently experienced in critical care units, operating rooms, labor and delivery, and emergency departments—areas that require seasoned nurses with extensive experience. Certainly, a shortage of highly experienced cardiovascular nurses in the intensive care units will affect the ability to sustain quality care and a low incidence of medical errors.
A number of factors have contributed to this nursing shortage. Applications to nursing schools are decreasing. In 1998, enrollment in U.S. nursing schools offering bachelor’s degrees fell 5.5% (5). The Boston Globe(5) noted that, in Massachusetts, the number of applicants admitted to such schools dropped 56% between 1994 and 1998. This article also reported that nursing organizations attributed the nursing shortage in part to “uncertainty over managed care, more diverse career options for young women, a shortage of nursing applicants, and a shortage of nursing faculty,” factors that have caused some schools to reduce enrollment. Women currently make up 90% of the nursing profession, and many have taken advantage of the widening variety of career choices available in today’s economy. Buerhaus et al. (6) noted that fewer young women appear to be choosing nursing as a career. These authors also identified a trend toward an aging nursing workforce. Between 1983 and 1998, the average age of working registered nurses increased by 4.5 years (6). In 1999, the average age of nurses in the U.S. was 45 years, and the average for nursing faculty was 55 years (5). Vivien Lubin (3) has reported that only 10% of registered nurses are younger than 30, which is down from 25% in 1980. According to Buerhaus et al. (6), by 2020, this trend toward an aging workforce will result in nursing availability that has declined 20% below the workforce requirements.
To compete in the face of a diminishing pool of nurses, hospitals in many parts of the country now provide signing bonuses of up to $5,000 and offer flexible hours and part-time working arrangements. Some hospitals have hired “traveling nurses,” which has increased costs. These travelers are usually nurses who are employed for three to six months when hospitals are understaffed.
Shortage of nursing school faculty
As noted, the faculty of U.S. nursing schools also is aging (5). If attempts to attract more nurses to pursue positions on the academic faculties of nursing schools are unsuccessful, then some nursing schools may reduce student enrollment or merely close. According to a recent survey reported in the Journal of Professional Nursing(7), noncompetitive academic salaries, desire for clinical practice opportunities, and rising expectations in higher education were the main factors deterring nurses with graduate degrees from pursuing faculty positions. The survey also found that better compensation, greater respect, closer proximity to work, more realistic expectations, and improved opportunities to continue clinical practice were viewed as incentives to entice practicing nurses into faculty roles. Many nurses contemplating careers in academic nursing do not do so because of the separation between education and practice. In many of today’s nursing schools, nursing faculty are not permitted or encouraged to maintain some clinical practice time. This is different from the medical school model, wherein academic physician faculty are both educators and clinicians. Physicians must do everything possible to support academic nursing school faculties and to encourage graduate nursing students to seek careers in academic nursing.
Shortage of allied health professionals
Shortages in allied health professionals can also be expected. Recruitment of pharmacists is a growing problem for pharmacy directors in hospitals and health systems (8). When the American Society of Health-System Pharmacists performed a national survey of 432 pharmacy directors, nearly 90% of respondents stated that the availability of pharmacy staff has declined by as much as 40% for entry-level staff and 70% for experienced candidates since 1999. Hospitals are also experiencing a critical shortage of job applicants in computer systems personnel and therapists (9). This survey found that jobs that require only minimal training, as well as those not directly involved in patient care, are being filled more easily (9).
Shortages affect quality of care
Severe shortages could have adverse effects on quality of care and patient outcomes because of greater chance of medical errors. Overworked nurses and allied health professionals, like overworked physicians, can make mistakes that could adversely affect patient outcomes. To combat the nursing shortage, some hospitals have replaced nursing positions with jobs for less-skilled workers. Michael Berens recently reported on a Chicago Tribune(10) investigation suggesting that poorly trained or overwhelmed nurses may be responsible for thousands of deaths and injuries each year in U.S. hospitals, many of which are understaffed. Berens indicated that, since 1995, at least 1,720 hospital patients have died and 9,548 others have been injured as a result of nurses’ errors. These data were derived from an analysis of three million state and federal records. The newspaper’s investigation found that many hospitals have increasingly turned to part-time nurses provided by temporary employment agencies. Berens stated that at least 119 patients have died under the care of unlicensed, unregulated nurse aides who earn an average of $9/h, and, in at least two Chicago hospitals, housekeeping staff were pressed into duty as aides for medication dispensing. Hospitals staffed entirely by registered nurses are now dependent on lesser-trained and lower-paid practical nurses and aides. According to the article, the American Nurses Association has proposed a research study to better explore the relationship between nursing staffing levels and medical errors.
What can be done?
The cardiovascular physician community, in concert with hospital administrators and professional medical societies such as the American College of Cardiology (ACC), should participate in discussions concerning how to solve the shortages of nurses and allied health professionals. We must do all that we can to retain nurses in their profession and allow for advancement in areas of nursing expertise. Nurses should be included in interdisciplinary groups, where they would collaborate with physicians to address issues such as quality of care, design and implementation of clinical pathways, and efforts aimed at cost reduction. Nurses and allied health professionals must receive the respect and recognition they deserve from the physicians with whom they work. Their contributions to patient care should be more appreciated, as evidenced by the fact that nursing retention is greater in medical environments where nurses feel valued and are treated as collaborators in caregiving. Job burnout must be identified and addressed, and measures should be instituted to prevent burnout among our most dedicated colleagues in nursing and the allied health areas.
The creation and branding of heart centers and cardiovascular institutes are important in providing an identity and an umbrella under which cardiovascular nurses and allied health professionals can flourish. Working side by side with physicians to fulfill the mission of delivering high-quality cardiovascular care to patients in these facilities is the key to sustaining dedication and loyalty. Feeling like part of a caregiving team is vital to sustaining morale and retaining the best people in the health care professions. We all must be aware of the shortages of nurses and allied health professionals, and we must encourage young women and men to enroll in nursing school, to become technologists, and to enter the medical field in other positions.
The ACC should play a larger role in the continuing medical education of cardiovascular nurses and allied health professionals. Nurses should be encouraged to attend the College’s Annual Scientific Session, extramural programs, and Learning Center courses. Some of the ACC’s online, Internet-based educational materials could be tailored to the interests and needs of these groups. It should be a high priority for physicians and the College to do our part to reverse these shortages of nurses and allied health care professionals, without whom we could not achieve the lofty goals we have for optimal quality care and high patient satisfaction.
I am grateful to Dr. Costas Lambrew, Ms. Marlene Bond, and Ms. Christine McEntee, who reviewed this essay, and to Mr. Jerry Curtis and Ms. Kathy Boyd for their excellent editorial assistance.
- American College of Cardiology
- ↵Gray BB. Another nursing shortage? You can bet on it. Nurse Week/Health Week. Available at http://www.nurseweek.com/97428/shortage.html.
- ↵Lubin VH. The new nursing shortage. Environmental Scan. Available at http://www.umdnj.edu.
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- Beller G.A.
- ↵Lahr EG, Lewis DE. Where the need is greatest, nursing shortage is most acute. Boston Globe 1999, Sept. 12. Available at http://www.calnurse.org/can/new2/bsg291599.html.
- Buerhaus P.I.,
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- Auerbach D.I.
- ↵Yasgur BS. Burnout fuels shortage of allied health staff. Internal Medicine News 2000, Sept. 1.
- ↵Berens MJ. Nursing mistakes kill, injure thousands: cost-cutting exacts toll on patients, hospital staffs. Chicago Tribune 2000;Sept. 10.