Nursing Shortage and Cultural Tensions at Community Medical Center

Introduction and Context

The Community Medical Center of Scranton, Pennsylvania is currently suffering a critical nursing shortage. While nursing shortages remain epidemic around the nation despite economic downturns, the Center's shortage is particularly acute. Furthermore, its retention rate is catastrophically low—the rate has dropped below 60%. As a point of comparison, in March 2005, a national poll of 138 healthcare recruiters found that the average national nursing turnover rate was 13.9% (AACN Fact sheet, 2009). The CMC's high dropout rate of new nurses means that the Center must continually retrain new staff while simultaneously dealing with the constant shortage of qualified nursing personnel.

This situation has created a burdensome demand on the Center's human and financial resources, even while community needs have expanded and CMC's financial resources have contracted. This paper examines the degree to which institutional and cultural tensions between younger, newly graduated nurses and older nurses compound the problems of retaining qualified nurses within the Community Medical Center. While the friction is part of a larger national issue—the widespread shortage of nurses nationwide—this analysis argues that generational and cultural factors specific to CMC significantly worsen the institution's retention crisis and require targeted intervention beyond standard recruitment and compensation strategies.

Institutional History and Current Performance

The Community Medical Center of Scranton, Pennsylvania has a long and proud history of serving the community. It began as a female-centered effort. In 1897, "a partnership of 15 women in Scranton, Pennsylvania, planted the seed for a new hospital dedicated to the people of their community." Currently, the center is staffed by 1,500 medical professionals and administrative employees. The hospital offers a wide range of services, including obstetrics, community education, emergency and traumatic care, and cardiac care. Additional services span diabetes management, hospice, pain management, physical therapy, and a Ronald McDonald House, along with MRIs and other routine diagnostic and treatment offerings.

According to U.S. News & World Report, Community Medical Center of Scranton is one of nearly 5,000 institutions ranked in the magazine's listing of America's Best Hospitals. Hospital satisfaction was rated at 62%, hovering at the national average, as was patient willingness to recommend the hospital to family members and friends. Nurses were rated high for courtesy and clarity. However, these ratings do not address the internal staffing crisis driving nurses away from the institution.

Pennsylvania hospitals have exhibited historically low rates of nurse retention. Dissatisfaction with nursing pay runs deep. The Altoona Regional Health System, for example, posted $19 million in total profits from 2004–2007 and increased CEO pay by 16% in 2006, but spending on nursing care remained unchanged (Towey 2007, p. 1). This disparity persists despite a widespread national mandate to increase nursing recruitment and retention.

The National and Regional Nursing Shortage

The aging of the population, the retirement of many current nurses, and a shortage of nursing faculty have all conspired to create small nursing class sizes and thus smaller ranks of new nurses nationwide. Many institutions are forced to turn away qualified applicants because of a lack of teachers and resources. According to the American Association of Colleges of Nursing (AACN), despite temporary easing of the nursing shortage due to recession, the U.S. nursing shortage is projected to grow to 260,000 registered nurses by 2025 (AACN Fact sheet, 2009).

Insufficient numbers of nursing graduates combined with high levels of nursing dissatisfaction and low retention rates compound the shortage. Nurses are often overworked and overburdened. In response, Congress authorized the Nurse Reinvestment Act of 2002, which included recruitment and retention strategies such as loan repayment programs and nursing scholarships, career advancement programs for young nurses, best practice grants, and a fast-track faculty loan repayment program for nursing students who agree to teach at a school of nursing (Addressing the nursing shortage: Background brief, 2010, Kaiser Permanente). In February 2009, the Nurse Education, Expansion and Development (NEED) Act, still pending, was passed to authorize Capitation Grants for nursing schools to increase faculty and student numbers (AACN Fact sheet, 2009).

However, many Pennsylvania regional hospitals have fallen short in fulfilling this national mandate to improve the quality of life of nurses. For example, "RNs in Altoona and the surrounding county had the 3rd highest rate of mandatory overtime of all of Pennsylvania's 67 counties," and nearly one third of RNs in Blair County reported being mandated to work overtime within the previous two weeks when surveyed (Towey 2007, p. 4).

To improve working conditions for nurses, some states have begun to pass legislation to reduce nursing stressors and factors leading to burnout. As of December 2002, eight states had implemented laws banning or severely restricting the mandatory overtime a nurse could be required to work. Despite this fact, complaints in Pennsylvania have continued about this practice. Nursing shortages and burnout have severe consequences for patients. A 2005 survey by Nursing Economics found that 79% of RNs agreed that the nursing shortage affects quality of patient care and 93% reported having major time-management problems that compromised patient safety (AACN Fact sheet, 2009). In 1999, California mandated specific patient-to-nurse ratios for its hospitals beginning in 2003, with nineteen other states following suit.

One of the much-anticipated positive effects of the recession was supposed to be improved recruitment of new nurses from the ranks of job-changing professionals. However, state nursing schools are facing budget cuts, which renders them less able to hire enough faculty members to train sufficient new nurses to meet projected needs. At the same time, health care philanthropies are crunched for cash and, as a result, are less able to provide nursing students and universities with the same levels of financial support they had provided in recent years. Consequently, fewer students may be preparing to become nurses—the opposite of what is needed to fill the projected need for as many as half a million nurses by 2025 (Has the recession solved the nursing shortage, 2009, RWJF). A shortage of faculty members means that many schools must turn away qualified applicants, while many qualified applicants are unable to complete their degrees due to lack of access to student loans and available credit.

The shortage in the market of nurses is likely to grow. The average age of registered nurses was 47 in 2004, according to the U.S. Department of Health and Human Services. While many older nurses may put off retirement for a few years for financial reasons, they cannot do so indefinitely. Meanwhile, fewer than 10 percent of registered nurses are under age 30, which means there will not be enough younger nurses to fill the shoes of their more senior colleagues when they do retire (Has the recession solved the nursing shortage, 2009, RWJF). Pennsylvania, unlike some of its neighboring states such as New Jersey and Ohio, continues to face a nursing shortage. Economic strategies have often been used to address the nursing shortage. However, "fewer RNs in 2006 than in 2004 perceived that hospital recruitment strategies were effective, particularly those that 'provided tuition benefit,' 'offered signing bonuses,' 'provided flexible work schedules,' and 'increased salaries'" (Buerhaus, 2010, p. 3).

Although CMC faces national and regional staffing challenges beyond its control, a significant internal factor compounds retention problems: the workplace culture and relationship between senior and newly graduated nurses. Nurses must labor under stressful conditions even under the best of circumstances, which is always a shock for new nurses. One recent graduate reported: "I knew I would have to work hard but this is beyond anything I imagined. I have to work harder, be more adaptable, the parameters change constantly. The expectations are huge" (Without support, 2008, The Lamp).

Workplace Culture and Generational Tensions

While a lack of time and stress may be endemic to the medical profession and the careers of both recent graduates and seasoned nurses, a critical concern reported by many new nurses is "the lack of available support and backup from experienced nurses" even when the new nurses show a readiness to learn from their older colleagues (Without support, 2008, The Lamp). The absence of mentorship is particularly damaging to retention. One new nurse reflected: "I think, is it worth it?" This type of inner dialogue propels many new nurses to leave the profession (Without support, 2008, The Lamp).

The root of generational tension lies partly in differing expectations and stress responses. A stressed and pressured environment that is understaffed can create tension rather than foster cooperation between nurses, particularly between older and younger staff members. Older nurses may believe that their younger colleagues must "pay their dues" before they are fully accepted as part of the nursing team. Younger nurses, in turn, may find themselves given more onerous tasks and denied learning opportunities, as they assume the "grunt work" of the nursing staff. Younger nurses feel frustrated with a lack of support and few opportunities to advance their knowledge in a pressured environment, where they are often "filling in" rather than learning to perform tasks properly. However, pressures to perform themselves can make older nurses brusque with younger nurses, perpetuating the cycle.

Sadly, no one benefits from such an adversarial culture. Younger nurses leave in greater numbers out of frustration, further compounding the nursing shortage at CMC. Little hands-on instruction and education means that new graduates lack confidence and autonomy in their decision-making and are more prone to error and reliance upon more skilled nurses. This creates a vicious cycle: understaffing leads to tension, tension drives away new nurses, and departing nurses worsen understaffing.

Quality of the work environment and a lack of respect by superiors and colleagues are often cited as influential in causing nurses to leave their jobs. Young nurses are especially apt to leave, as they suffer "heavy workloads, pressure from patients and colleagues, lack of support and recognition, and inadequate compensation for the hassles of night shifts and holidays" (Without support, 2008, The Lamp). Greater financial constraints make it all the more essential to improve conditions for nurses and foster a positive workplace culture. Financial incentives such as scholarships, raises, sign-in bonuses, and monetary incentives for relocating to the community are not available at CMC. Moreover, a sharply graduated pay scale favoring more experienced staff or tuition reimbursements that favor younger staff members could increase rather than decrease generational tensions.

Using the organization's human resources is the most effective solution to the retention problem. Specifically, creating mentorship opportunities between older and younger nurses would foster greater staff cohesion and create a common culture between experienced and new staff. Assigning each new nurse an experienced mentor nurse would demonstrate that CMC makes a commitment to educating new nurses and integrating them into the team. This approach would also improve retention: the personal relationship established through mentorship would make the newer nurse less apt to leave the organization and disappoint her mentor. Conversely, older nurses would benefit from increased retention of new nurses and reduced mandatory overtime as the ranks of nursing staff increased through improved retention.