"It was something that was like a burning desire," said Crowell, a Georgetown resident who works at Beebe Medical Center's Tunnell Cancer Center in Lewes. "I wanted to give something back."

Sure, the work is tough. Like all nurses, she has to deal with the pressures of having someone else's life in her hands.

"But it's just this gratification you get from patients," she said. "I love my job. It's not easy and we work hard, but you feel good coming home. And you feel good coming to work. A lot of people don't have that luxury."

Delaware would like to find more people like Crowell. The state needs about 800 more registered nurses than it has, and that shortage is expected to grow more critical. By next year, Delaware could be short by more than 2,126 nurses, or 29 percent, according to a study by the federal Health Resources and Services Administration. In 2020, Delaware will have only half the number of nurses that it needs.

"It's not going away anytime soon," said Joe Letnaunchyn, president of the Delaware Healthcare Association. "There's still a challenge of being able to meet the need and provide the ongoing educational opportunities for people interested in nursing and the allied health professions."

Statewide, one in 10 nursing jobs is vacant. The shortage is most critical at the five state-owned, long-term care facilities, where nearly a third of nursing jobs are vacant.

Experts attribute the shortage to a variety of factors:

• The aging population is causing the demand for nurses to swell.

• Advances in health care treatments that did not exist years ago are creating more demand for nursing staff.

• Women who traditionally flocked to the nursing field have more professional opportunities today.

• Nurses have more opportunities to work in non-hospital settings, such as offices and outpatient surgery centers, which do not require staff 24 hours a day.

• Pay in nursing has been relatively flat for some time.

• It's a difficult job.

"The nurses in the profession think it's the best job in the world. But it can be physically difficult, very stressful and emotionally draining," said Carol Cooke, a spokeswoman for the American Nurses Association. "Couple that with a work environment that doesn't pay what it should, and it can be a pretty dire picture."

Nurses account for about half of all health care workers, and studies show that they play a key role in monitoring patients' health status. Inadequate numbers of nurses are associated with increased infections, bleeding and cardiac and respiratory failure, studies show. About 53 percent of physicians and 65 percent of the public cited the nursing shortage as a leading cause of medical errors, according to a 2002 survey published in the New England Journal of Medicine.

The crisis is worsening nationally and locally because of the graying of health care workers and consumers. There has been explosive growth in Delaware's retiree population, particularly in Sussex County. The nurses, too, are getting older, and there is concern that as they retire, there won't be enough young nurses to replace them. The average age of a nurse is 45 nationwide and 43 in Delaware. Only 9 percent of nurses nationally are younger than 30.

"A lot of nurses are going to be going into retirement age," said Nancy Rubino, president of the Delaware Nurses Association. "If we don't replace them, our shortage is going to be dramatic."

Working long hours

The shortage has meant that more nurses are asked to work overtime, and more health facilities hire nurses from temporary agencies to fill the gaps. But those solutions have created new challenges.

More than two-thirds of nurses work overtime each month, according to a survey by the American Nurses Association. While some nurses welcome overtime, burnout is a risk.

"Any nurse that wants overtime can get it. But we're all trying to be judicious as to how much overtime to give," said Yrene Waldron, executive director of the Delaware Health Care Facilities Association. "If a nurse works three 15-hour shifts in a row, by the third day, she is burned out and tired. And is her judgment going to be good?"

Hiring nurses from temporary agencies avoids overtime but carries a high cost. The average hourly wage for an agency registered nurse in Delaware was $49.81, compared with $29.44 for a staff registered nurse, according to a survey of the state's nursing wage rates.

Temporary nurses get expensive for long-term care facilities such as the state-owned Emily P. Bissell Hospital, which has a 67 percent vacancy rate for nurses. Hospital officials say that, while they use temporary nurses for some jobs, they cannot provide all the services of a staff nurse.

"We really need to have our own staff for the continuity of care and for documentation purposes, to do comprehensive assessments on the residents," said Janet Parr, director of nursing at Bissell. "Unless they're here all the time, they can't do that."

Three-year-old state nursing home reforms require long-term care facilities to provide a minimum of 3.28 hours of nursing care to each patient each day. Meant to ensure that there were no gaps in care, those rules and the nursing shortage have forced the long-term care facilities to reduce the number of beds they have. The state had to reduce the number of patients in its five facilities from 440 to 378.

"It's not a situation we want to be in, but we don't have a choice," said Vince Meconi, secretary of the Delaware Department of Health and Social Services. "You can't be in a situation where you have staff not providing the standard of care and you're putting patients at risk."

State gets involved

Last year, the state made an effort to help find a long-term solution: train more nurses.

Gov. Ruth Ann Minner announced a $1.8 million program to pay for new faculty positions at Delaware Technical & Community College.

The state also provided $125,000 in scholarships to 52 students to attend nursing programs at Beebe Nursing School, the University of Delaware, Delaware State University, Wilmington College and Wesley College. In exchange for the scholarships, students had to commit to work at local hospitals, long-term facilities or one of the Department of Health and Social Services facilities after graduation.

In addition, the state provided $204,171 through its Department of Health and Social Services, Health Care Association and Health Facilities Association to 63 students at Delaware Technical & Community College.

Some schools are clamoring for more. Last year, Beebe accepted 62 students. But half of them were put on a waiting list because of limited space. Beebe is trying to get federal funds to finance a $3.4 million expansion for its school of nursing to add classes and lab space.

Expanding the capacity of the 83-year-old nursing school is particularly crucial because a significant portion of the students stay to work at Beebe after they graduate. About 20 of the 26 students stayed at Beebe last year to work.

Work incentives

Hospitals have taken action on their own, trying to woo nurses with signing bonuses, free education and by selling the profession as fun.

Beebe has run ads featuring nurses clad in scrubs and sunglasses with beach balls in hand. The hospital has also tried to bring levity to the work environment, with plenty of office parties, picnics, Hawaiian shirt days and even by bringing in a professional humorist for National Nurses Week.

"Health care is very stressful, and we want our employees to feel some lightness in this stressful environment they walk into," said Bonnie Burke, a human resources specialist with Beebe, where 3 percent of nursing positions are vacant.

At Bayhealth Medical Center, 2.9 percent of nursing positions are vacant, down from 9 percent a year ago, according to Judy Martin, senior vice president for patient care services. She attributes that, in large part, to a hospital-wide re-evaluation of the hiring and retention process. The hospital has created a mentoring program, a six-month fellowship and an environment more conducive to professional advancement.

At Alfred I. duPont Hospital for Children in Rockland, the vacancy rate is 7.5 percent. The hospital has established a summer extern program for nursing students who have completed a clinical rotation, and an internship for the pediatric intensive care unit. It also offers loan forgiveness and tuition reimbursement.

At Christiana Care, about 5 percent of nursing jobs are typically unfilled. Recruitment has benefited from its recent ranking among the top 5 percent of all hospitals for clinical excellence by HealthGrades, a national health care quality ranking firm, said Joan G. Thomas, senior vice president for facilities and services at the hospital.

The hospital is working to get certification through the American Nurses Association's nursing excellence program. The program requires the hospital to meet certain standards established by the national trade group. Those standards include involving employees in key decision-making roles and having an atmosphere that is conducive to their career advancement.

One of the keys to retaining nurses in the long term has been getting them the resources they need to meet the physical demands of the job, Rubino said. Fewer than 20 percent of nurses feel safe in their current work environment, according to the American Nurses Association. And the top concerns at work are a disabling back injury or contracting HIV or hepatitis.

Given the aging work force, getting the proper and state-of-the-art equipment is particularly important.

"Just making those simple things available would make a big difference," Rubino said. "Once we get them in there, we have to make sure that the environment that they're working in is one that keeps them there. Right now there are a lot of other employment opportunities that can attract people away from our profession."

At St. Francis Hospital, about 8 percent of nursing jobs are vacant. For the past 18 months, a group of senior hospital leaders has been evaluating salaries, benefits, sign-on bonuses and opportunities to give nurses more autonomy in their work and more education. One challenge is recruiting the kind of people who are going to be in the profession for the long haul.