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Previous Volume 354:1648-1649 April 13, 2006 Number 15 Next

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To the Editor: Like many others who discuss remedies for the shortage of nurses, Chaguturu and Vallabhaneni (Oct. 27 issue)¹ mention the issue of pay only in passing and emphasize such nebulous measures as the "creation of work environments that are challenging yet rewarding." Yet unrewarding working conditions cannot be the heart of the problem. Chronic shortages do not arise in other occupations with difficult working conditions, because the pay stays high enough to induce a sufficient supply of workers to endure them. We need to pay more attention to hospital practices that keep nurses' wages from rising enough to prevent the shortage from continuing.

The market for nurses is split into metropolitan areas, each dominated by a relatively small number of large employers, which facilitates anticompetitive behavior. We know that some hospitals have engaged in agreements to refrain from offering higher wages to attract nurses working for other hospitals in their area.² In 1996, the Department of Justice and the Federal Trade Commission, which are aware of this problem, issued guidelines for hospitals that defined anticompetitive behavior,³ but stronger measures are needed. One measure could be the filing of a rash of antitrust suits by groups of nurses. At this writing, such suits are in preparation in a number of metropolitan areas. Another measure could be a drive for minimum nurse-to-patient ratios nationwide. If such measures increased pay and as a result attracted more new nurses and reduced departures, then working conditions, which are affected by staffing shortages at hospitals, would improve. Nursing schools, which have contracted, would expand. A 10 percent increase in nurses' pay and a 10 percent increase in the number of nurses employed would add about 1 percent to the nation's overall cost of health care.⁴

Barbara R. Bergmann, Ph.D.
American University
Washington, DC 20016
bberg{at}american.edu

References

1. Chaguturu S, Vallabhaneni S. Aiding and abetting -- nursing crises at home and abroad. N Engl J Med 2005;353:1761-1763. [Free Full Text]
2. United States v. Utah Society for Healthcare Human Resources Administration, No. 94 CV 282, (D. Utah C.D.) complaint for equitable relief for violations of 15 U.S.C. 1, Sherman Antitrust Act, filed March 14, 1994.
3. Statements of antitrust enforcement policy in health care. Washington, D.C.: Department of Justice, Federal Trade Commission, August 1996:49-50.
4. Median weekly earnings of full-time wage and salary workers by detailed occupation and sex. Washington, D.C.: Department of Labor, 2005. (Accessed March 23, 2006, at http://www.bls.gov/cps/cpsaat39.pdf.)

A General Accounting Office report cites several studies that explored this issue.² Of nurses who had considered leaving the patient care field, 18 percent wanted more money, whereas 56 percent were concerned about the stress and physical demands of the job. Another study showed that 39 percent of nurses were dissatisfied with their compensation, but 48 percent were dissatisfied with the level of recognition they received from their employer. In another survey, 57 percent of nurses were satisfied with their salaries, but only 33 percent felt that their facilities were adequately staffed, and only 29 percent felt that the hospital administration responded to their concerns.³

The approach to addressing the nursing shortage should be multifaceted; increasing wages alone may in fact exacerbate the "pull" factor for nurses from the developing world.

Sreekanth Chaguturu, M.D.
Massachusetts General Hospital
Boston, MA 02114

Snigdha Vallabhaneni, B.A.
Brown Medical School
Providence, RI 02912

References

1. National Center For Health Workforce Analysis. Projected supply, demand, and shortages of registered nurses: 2000-2020. Washington, D.C.: Health Resources and Services Administration, July 2002. (Accessed March 23, 2006, at http://bhpr.hrsa.gov/healthworkforce/reports/rnproject/report.htm#chart7.)
2. Nursing workforce: multiple factors create nurse recruitment and retention problems. Washington, D.C.: General Accounting Office, 2001. (Accessed March 23, 2006, at http://www.gao.gov/new.items/d01912t.pdf.)
3. The Lewin Group. The hospital workforce shortage: immediate and future. Vol. 3. No. 2. TrendWatch. June 2001. (Washington, D.C.: American Hospital Association.)

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