BBI Contributing Writer

News of the nursing shortage has now reached the majority of the American public with 81% aware that there is a shortage, 93% believing that the shortage threatens the quality of patient care and 65% believing the shortage is a major problem. Initially, the nursing organizations and others that were reporting this shortage projected numbers that staggered the imagination. While these numbers are still alarming, there now seems to be some concrete action toward lessening the worst-case scenario.

The recently released Joint Commission on Accreditation of Healthcare Organizations (Oakbrook Terrace, Illinois) report, Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis, indicates how seriously people are taking the shortage. From the preamble to the final conclusions, this report is positive and powerful in its conclusions and in assigning accountability. The report focuses on three major areas, covering the need to:

1. Create organizational cultures of retention.

2. Bolster the nursing educational infrastructure.

3. Establish financial incentives for investing in nursing.

The report incorporates data from these three areas that will foster further progress in addressing the problem of the shortage of nurses. Some of the highlights of this data include:

41% of nurses currently working reported being dissatisfied with their jobs; 43% scored high in a range of burnout measures; and 22% were planning to leave their jobs in the next year. Of this latter group, 33% were under the age of 30.

One report showed that there is almost perfect correlation between hospital employees' satisfaction and patient satisfaction.

It costs around 100% of a nurse's salary to fill a vacated nursing position. For a medical/surgical nurse that cost is $46,000 a year and for critical care nurses the cost is $64,000 annually. That translates to $5.52 million a year in replacement costs for a hospital employing 600 nurses (assuming a turnover rate of 20%). This report demonstrates that organizations with higher turnover rates (21% or more) had a higher cost-per-discharge (36%). Higher turnover led to lower profitability.

56% of nurses said that the reason they left patient care (other than for retirement) was to seek a job that was less stressful and less physically demanding. They listed the biggest problem with nursing as that of understaffing.

In a survey of nurses describing their last shift, 31% reported that their patients did not receive necessary skin care, 20% reported that their patients did not receive oral care, 28% were not able to give patients the necessary education or instruction and 40% said that they were not able to comfort or talk to their patients. Almost 70% of these same nurses said that they had to perform non-nursing tasks (ordering, coordinating, etc.) because of shortages of support personnel.

An American Hospital Association (Chicago, Illinois) study found that for every hour of patient care, 30 to 60 minutes were spent on the subsequent paperwork.

40% of nurses reported that they have been injured on the job, and 75% of nurses surveyed stated that unsafe working conditions interfered with their ability to provide care. Nearly 90% of nurses surveyed indicated that health and safety concerns influenced the type of nursing they did and the likelihood of their continuing in the practice. In spite of the availability of safe needle devices, 18% of nurses surveyed by the American Nurses Association (ANA; Washington) indicated that these devices were not provided at their institution.

The same ANA study found that one-third of all workplace injuries were ergonomics-related.

Many of the above bullet points have direct impact on or represent potential opportunities for a variety of medical device vendors. Fewer nurses have been correlated with longer lengths of stay, higher costs, lower profits and increased adverse events due to complications such as increased nosocomial infection rate, increased catheter infection rate and increased numbers of decubitus ulcers (bedsores) as well as increased complaints by patients and their families.

There is a great need for the medical community to partner with companies that develop innovative new products to improve the efficiency of the nurses who remain. Hill-Rom (Batesville, Indiana), for example, already has developed a tilting bed that helps patients avoid pneumonia, as well as bed sores two very expensive and serious complications of being bed bound. There are a multitude of opportunities for many vendors to join in and assist nurses to deliver better patient care by reducing known problems.

Any one of these findings should spark a deluge of ideas for new or transformed products products designed with nurses as the end users and not just as someone who needs to be catered to in the process of selling equipment to hospitals. Johnson & Johnson (J&J; New Brunswick, New Jerey) is leading the way by focusing on how to improve nursing's fortune. We recently attended a fundraising dinner put on by J&J. The company hosts five of these regional dinners around the country each year. They contact hospitals and other healthcare institutions, as well as vendors in a region, and ask them to make a donation, specifically by "buying" a table. Then those institutions send some of their nursing staff as a "thank you" for a job well done. All of the money raised goes to fund that region's nursing scholarships and to finding solutions to the shortage of nurses and nurse educators.

The nurses who attend these dinners are given a gift bag at the evening's conclusion that contains samples of J&J products (Neutrogena foaming cleanser, liquid makeup, face lotion, Tylenol PM, etc.) and also information on numerous J&J medications. Will this influence nurses when buying decisions are made? When James Lenehan, president of the company, stood, he received a longstanding ovation by all in the room.

Lenehan presented the following statistics as a soft sell, since J&J's Campaign for Nursing's Future was well known by all in attendance:

The American Association of Colleges on Nursing reported that baccalaureate nursing school enrollment increased by more than 8% between 2001 and 2002. Moreover, 84% of nursing schools are experiencing rising applications and enrollments.

According to a recent Harris interactive survey, 75% of adults and 67% of teens would view "very positively" news that a family member or friend was seriously considering a nursing career.

There has been an increase of 40% in the number of visits to the J&J nursing promotion website (, bringing the total visits to more than 390,000 and in excess of nine million individual page hits.

Becoming more significant in the process

Vendors need to decide if nurses are becoming more influential in the hospital procurement process and brand selection. If they are, some vendors will need to reeducate their sales forces and/or use sales people with stronger clinical backgrounds. Medical Strategic Planning (Lincroft, New Jersey) recently analyzed a monitoring system procurement at a mid-sized U.S. hospital. There were initially four vendors involved two market leaders and two smaller vendors, one of which was about to be acquired by another vendor involved. There was a significant spread in the bids for the equipment this hospital needed. The network it belonged to was a member of a group purchasing organization (GPO) with a monitoring contract that enforced "strict compliance" with one of the higher bidding vendors.

Eventually, the lowest-priced vendor, which had been the incumbent vendor at this hospital and was well-liked, was eliminated because it was being acquired and uncertainty surrounded its future. The highest-priced vendor, one of the two market leaders in the industry, also was eliminated. This left two competitors a vendor with a large U.S. market share and a vendor with a small market share. The larger vendor offered a higher-priced bid and the small vendor offered a lower-priced bid, with the bid spread being several hundred thousand dollars. There was also an independent consultant involved who worked with the clinical staff throughout the process.

Based on site visits and initial presentations, the smaller vendor was preferred by the clinical staff and seemed to be the vendor of choice to get the equipment order. The consultant also sensed the staff was favoring the smaller, lower-priced vendor and that the larger vendor had little chance. In the end, however, the larger, higher-priced vendor got the order.

Why did the smaller, initially favored vendor lose the order that everyone felt was in the bag? Not because of the hospital's GPO, as many speculated, but rather because the RN staff had switched vendor preferences in mid-stream. In doing so, the clinical staff had the complete support of the hospital's purchasing department and administration and total freedom to choose either vendor, in spite of the GPO membership. That's growing influence.

It appears that the influence of GPOs will continue to weaken a bit as the nursing crisis continues to emerge. Nursing workflow efficiency and satisfaction is key to excellent outcomes and getting nurses the equipment they determine works best to improve both workflow efficiency and patient outcomes. GPOs that want to maintain hospital support will increasingly need to take this into account in letting vendor equipment contracts or mandating compliance levels.

Importance of the local sales representative

Often a vendor's local sales personnel don't realize how important they are to the ultimate outcome of a negotiation. One company aware of this is patient monitoring market leader Philips Medical Systems (Andover, Massachusetts). Philips increasingly deploys sales personnel with previous nursing or other clinical backgrounds. This expertise enables the vendor representative to have empathy for, and understand the needs of, hospital clinical personnel in caring for the growing population of increasingly ill patients. Philips also uses win/loss debriefing for key orders it loses to keep informed of its weaknesses.

Vendors who continue to use the traditional, non-nursing, high-pressure or clinically-uninformed sales types may have increasing difficulty making the connection with busy clinical personnel who will have little time or patience with salespersons who can't discuss nursing needs and product applications from a user-clinical perspective.

Clinical personnel are looking for the best clinical solution and want to talk about a vendor's proposal on their terms without having to learn a lot of technical jargon. In the case cited earlier, the larger vendor's salesperson made it her business to understand the issues the nurses dealt with every day. She did her homework concerning these clinical problems and the product solutions her company could offer. This salesperson never criticized competitors, but instead concentrated on the hospital's needs and future vision.

The hospital perceived the local representative from the larger vendor as better understanding its clinical needs, an opinion that crystalized during a walkthrough of the hospital. Walkthroughs are intended as a review of clinical needs and equipment configurations and help both the hospital committee members and vendors to better understand a hospital's real hidden needs.

The walkthrough that lost the order

The clinical walk-through with the personnel from the smaller vendor is what actually lost his company this order. Rather than just the local salesman the hospital committee already knew going on the walkthrough, two additional managers from the company's headquarters showed up unannounced. Surprised by the unexpected presence of these additional vendor representatives and concerned about the potential disruption of so many people walking through each clinical unit, the hospital's clinical managers restricted the walkthrough to two people, the salesperson and one visiting manager.

During the walkthrough, rather than focusing on clinical needs, the second vendor's personnel asked numerous competitive, rather than clinical questions. They appeared to be more concerned with the competitive situation than with any of the hospital's clinical issues and raised none of the clinical issues that the salesperson from the larger vendor had raised. This was a disappointment to the hospital's selection committee nurses. Since they were interested in how the smaller vendor might solve some of the clinical issues raised by the larger vendor on their walkthrough, the hospital staff asked for similar feedback from the smaller vendor.

When the smaller vendor's personnel responded to the issues raised, they disagreed with, contradicted and interrupted each other. The impression conveyed to the staff was that this vendor's field team was not as professional as the larger vendor's. The clinical personnel on the selection committee found that their initially favored vendor did not offer answers that were as good as the larger vendor, which caused them to reassess both companies and ultimately resulted in the larger company getting the order in spite of its higher bid. The point is that for the hospital, the local rep is the one who reflects a company and its values. Vendors should remember that most orders are won on overall value perceptions rather than who offers the absolute lowest bid price.

The losers in any deal need to assess what key issues need to be addressed. In this case, the company that lost might want to ask: Was the clinical training of the company's sales personnel adequate and consistent across their entire sales organization? Was the intervention of the company's divisional management personnel appropriate in this situation? Does the company understand what the nursing shortage means to personnel at the bedside? Could the company change its approach to selling, perhaps by becoming more clinical staff-focused?

Companies are limited in doing this, however, if they only have feedback from inside their organizations. Vendors have a wonderful opportunity to make a contribution to solving the problem of the nursing shortage for nurses' profit, but also for their own company's bottom line, if they are willing to re-engineer some products, orient their sales organizations and listen to their customers.

As has been repeatedly stated, the current nursing shortage is unlike any other, and as baby boomers age, it will worsen. Vendors will have to look anew at their products' features and benefits, product positioning, sales training and sales force makeup to fine tune their value propositions; making them more nursing- and work flow-focused in the future. They also need to put external win/loss analysis in place in order to assess how they are doing and what can be improved, with a wide variety of medical intelligence firms available to provide such service.