Fewer nurses for fuller nursing homes

When Rhode Island held a job fair at the Providence Civic Center a few weeks ago, Judith Robidoux was there. As director of nursing at the Waterman Heights Nursing Home in nearby Greenville, she was seeking to recruit nurses and nurse's aides. So were the representatives of half a dozen other health organizations.

Ms. Robidoux was making an effort to deal with one of the most serious problems facing nursing homes and other groups that provide long-term care to elderly Americans: not enough nurses.

``There is a real shortage,'' says Paul Willging, executive vice-president of the American Health Care Association, which primarily represents nursing homes across the United States. ``Two-thirds of our members have nursing vacancies; one-third of them have vacancies that'' force them to have staff members to work double shifts or take similarly extraordinary measures to meet state and federal standards.

Experts say today's problems will worsen unless more Americans enter and remain in the fields of nursing and nursing aides. Health-care facilities ``will need 29 percent more employees by 1995'' just as the pool of prospects for low-skilled jobs, such as nurse's aides, is shrinking, says James Paxton. As vice-president for human resources of Beverly Enterprises, he works for America's largest nursing-home chain, with nearly 1,100 facilities.

``We compete for unskilled employees'' with hotels, schools, government, and restaurants, Mr. Paxton says.

The US Department of Labor forecasts that the demand for nurses and nurse's aides will rise much faster than the average for all occupations through the year 2000. Behind this demand is the immense growth forecast in the number of elderly Americans: They make up 90 percent of those requiring long-term care, such as help in walking, dressing, and caring for themselves.

Moreover, new federal and state regulations will soon require added nurses and better trained aides in nursing homes. Yet ``nursing schools are closing,'' Mr. Willging says. ``Enrollment is dropping dramatically.''

Nursing homes and other long-term care facilities face other serious problems: the amount government programs pay them; the paper work these programs require; and the slow pace of construction of care facilities. There's also the persistent issue of the quality of care, widely agreed to be much better than in the 1970s but still far from first rate in many places.

Finally, there is the challenge of planning for the future. Will technological improvements in medical care mean that, as some experts say, many more Americans, such as accident victims, will be cared for in nursing homes, with a resultant need for bigger staffs? Or will it mean a dramatic increase in at-home care, meaning a lower-than-expected demand for institutional staffs?

Will the US develop a policy on long-term care, as the result of the many proposals now being considered? If so, how will this policy affect nursing homes?

The heart of a nursing home is its staff - the nurses who are largely responsible for planning care and supervising it; and the aides, who provide 90 percent of the day-to-day care. Without enough trained staff members, the quality of assistance is compromised.

In the short run, the efforts of resourceful institutions like Waterman Heights Nursing Home can pay off. Judith Robidoux called her day at the Rhode Island job fair very successful. She talked with more than 100 prospects and gave out 75 applications: ``If I get 5 to 10 good employees, it will be well worthwhile.''

Dealing with the long-run problem of nursing shortages requires national planning. Consequently, a commission on nursing appointed by the US Department of Health and Human Services is studying the problem. In December it is to report its findings and recommendations to Otis Bowen, secretary of the department.

``I think that a major part of the problem is that nurses have been paid relatively little and treated relatively badly,'' says William Roper. Therefore, many of those trained as nurses ``aren't working as nurses,'' he says. As administrator of the Health Care Financing Administration, Dr. Roper is the federal government's top official in charge of programs, like medicaid, which pay a little less than half the nation's nursing-home costs.

The Labor Department says that in 1986 the median salary of full-time registered nurses in the US was $23,900. Those who worked in nursing homes were generally among the lower-paid half - in 1987 their median salary was $19,900. As Robidoux of Waterman Height says: ``We're competing with the hospitals to get nurses, and the hospitals can pay higher salaries.''

When former and current nurses discuss problems in their profession, almost inevitably they mention the lack of respect accorded them, especially in hospitals.

Experts and nurses themselves say higher salaries would help. But for nursing homes that would mean higher costs, which would be passed on to patients and their families in higher charges. Already Americans in nursing homes are paying an average of $22,000 a year.

Administrators and other experts on long-term care say that, in an effort to hold down costs, medicaid often reimburses nursing homes for less than the cost of the actual care. The program is jointly funded by the federal government and individual states; the latter determine the amount that will be paid, which varies state to state.

``Some states are paying in the low $30s for a day of nursing home care,'' says Willging. This doesn't cover the actual cost, he says. Who makes up the difference? It's the patient who pays privately. He frequently is charged more than the actual cost in what is a de facto subsidy of medicaid patients.

Beyond salary is training. To provide quality, Beverly Enterprise's Paxton says, nursing homes ``must provide very skilled training to the unskilled.''

Retaining nurse's aides is almost as difficult as recruiting them. ``Being a nurse's aide is awfully tough,'' Willging says. ``Some parts of it can be very unappealing,'' such as aiding patients who have lost control of their bodily functions. ``Turnover rates approach 200 percent in some homes,'' he says. ``You'll have three people filling the position in some homes'' in a year.

One way to help retain aides, experts say, is to build a career ladder for them. Besides providing higher pay and more respect, Paxton says, ``we must also provide career options....''

Finding the right employee in the first place is also essential. ``The successful nursing-home employee,'' Paxton says, ``has a strong piece of nurturing and caring in his personality. ... I think we have to remember that a nursing home is a person's home.''

Despite the lower pay, some registered nurses cite advantages to working for nursing homes and home-care agencies: Nurses have more respect and greater responsibility for patients' care.

Hospitals, where three-fourths of America's nurses are employed, are what one nurse calls ``doctor driven'': Physicians make the decisions. Nurses say they often feel they are rushing around carrying out physicians' orders without being able to fully use their own knowledge and abilities.

It's different in nursing homes and at-home care: Nurses do much of the planning to see that patients' needs are met.

``I like my work because I teach people,'' says Phydariel Jackson, a registered nurse with the Visiting Nurse Association of Washington, D.C. Ms. Jackson, who has a gift for gaining the trust even of recalcitrant people, visits patients in their homes and helps family members learn to care for them. ``I like the independence of it,'' she says quietly, ``and the people are so nice, too.''

Third of five articles. Next: care at home.