There is no
simple description of the status
of the nursing workforce
shortage - present and future.
Discussion surrounding this
issue is complex and
interrelated. It is not possible
to isolate single factors or
solutions. Rather, a systems
perspective review gives the
greatest depth and understanding
of the relationships between
multiple variables. It is
critical to include the
systematic issues in education,
health delivery systems and the
work environment. Further, the
impact of reimbursement,
legislation, regulation and
technological advances must also
be considered. Failure to
consider the relationships among
these aspects limits the full
appreciation of the nursing
workforce shortage complexity.
The
Tri-Council is an alliance of
four autonomous nursing
organizations each focused on
leadership for education,
practice and research. While
each organization has its own
constituent membership and
unique mission, they are united
by common values and convene
regularly for the purpose of
dialogue and consensus building.
The Tri-Council's diverse
interests encompass the nursing
work environment, health care
legislation and policy, quality
of health care, nursing
education, practice, research
and leadership across all
segments of the health care
delivery system. Member
organizations believe the
alliance captures the
collectivity of nursing's
social, political, professional
and moral authority nationally
and internationally to influence
and provide stewardship within
the profession of nursing. These
organizations represent nurses
in practice, nurse executives
and nursing educators.
The New
Nursing Shortage
Today's nursing
shortage is very real and very
different from any experienced in
the past. The new nursing shortage
is evidenced by fewer nurses
entering the workforce; acute
nursing shortages in certain
geographic areas; and a shortage of
nurses adequately prepared to meet
certain areas of patient need in a
changing health care environment. As
a result, there is a growing
realization that the supply of
appropriately prepared nurses is
inadequate to meet the needs of a
diverse population - and that this
shortfall will grow more serious
over the next 20 years.
The actual size
of the nursing shortage is difficult
to quantify. Registered nurses
currently comprise the largest
number of health care professionals
in the United States. Statistics
from the U.S. Department of Labor
and from studies within the nursing
profession indicate there has been a
steady increase in nurses entering
the profession that would appear to
be sufficient to fill nursing jobs.
Indeed, according to U.S. Bureau of
Labor statistics, growth in actual
job demand for nurses dropped during
the years 1992 to 1997 to an annual
average of 2.7 percent. This
compares with a 3.6 percent annual
average job growth rate for the
previous six years. During roughly
the same time period (1992-96)
surveys within the nursing
profession show that the number of
registered nurses employed in
nursing practice rose annually by an
average of 3.4 percent culminating
in an employment rate of nearly 83
percent of the registered nurse
population in 1996.
Numbers are
Deceptive
Traditional
employment statistics are deceptive
and inadequate to measure the scope
of what is actually taking place in
health care. Research indicates that
the standard dynamics of supply,
demand and need with regard to
nursing have been altered by
variations in health delivery
systems, Medicare and Medicaid
reimbursement and even by regional
and local customs and culture. How
care is delivered, where it is
delivered and how it is paid for are
issues that directly impact the need
for nursing services. Moreover, the
increasing age of the general
population and the growing need for
management of chronic disease
conditions suggest that the overall
requirement for nursing services
will increase.
The current,
aging nursing population and the
declining number of nursing
professionals in the academic
pipeline indicate that the nursing
shortage will only grow more serious
as time ensues. The National Council
of State Boards of Nursing (NCSBN)
reports that the number of
individuals taking the NCLEX exam
each year has declined consistently
since 1994. The American
Organization of Nurse Executives (AONE)
reports that in areas where the most
acute shortages seem to exist, some
hospitals are closing units,
diverting patients, and canceling
surgeries because there are not
adequate numbers of professional
nursing personnel.
Disturbing
Future Trends
One of the most
critical problems facing nursing and
the nursing workforce is the aging
of nurses and nursing faculty. The
present average age of employed
registered nurses is 43.3 years,
with registered nurses who are less
than 30 years old representing only
10 percent of the total working
nurse population. According to the
American Association of Colleges of
Nursing (AACN), nursing school
associate professors and assistant
professors are an average age of 52
and 49 years. These figures track
with the average age of medical
school professors, 45 percent of
whom were age 50 to 59, and with
pharmacy professors, 46 percent of
whom were age 50 to 59 at the time
of the survey. However, this
comparison does not hold true with
regard to new doctoral recipients
within the health sciences and other
fields. In 1996, the average age of
new doctoral recipients within
nursing was 45 years. According to
the National Research Council and
the National Opinion Research
Center, the average age of new
doctoral recipients was 34 in all
fields, 39 in the health sciences,
and 44 for education majors. The
aging of nursing faculty will impact
the capacity of nursing schools to
educate sufficient numbers of
registered nurses to meet future
demand.
These numbers do
not address the skills, capabilities
and educational mix that are
required to meet health care needs
today and for the foreseeable
future. Enrollments in all basic RN
preparation programs have declined
each year for the last five
consecutive years. According to the
National League for Nursing (NLN),
between 1995 and 1999, the number of
programs of most types has increased
in the United States. Despite this
overall growth in the total number
of nursing programs (from 3,137 to
3,220 or 2.6 percent), the number of
students enrolled in and graduating
from nursing programs has declined
with the exception of a 4 percent
increase in doctoral programs.
Consistent with enrollment declines,
an overall decline in graduations
from all types of programs was 13.6
percent between 1995 and 1999. The
clear trend is toward an increase in
the number of programs occurring
simultaneously with a decrease in
the number of enrollments and
graduations from those programs.
The National
Advisory Council on Nurse Education
and Practice (NACNEP) has
recommended that by 2010 at least
two-thirds of all registered nurses
hold baccalaureate or higher
degrees. Presently, only 32 percent
of registered nurses are prepared at
the baccalaureate level and an
additional 10 percent educated at
the master's level or above. NACNEP
projects that only 36 percent of the
total registered nurse population in
2010 and 37 percent in 2020 will
have a baccalaureate degree as their
highest level of preparation.
Based on these
and other statistics from the
National Sample Survey of Registered
Nurses, the Division of Nursing
within the Bureau of Health
Professions predicts that demand for
full-time equivalent RNs will begin
to exceed supply by 2010. The gap is
expected to grow wider in ensuing
years - particularly if nothing is
done to promote the retention of
older and more experienced nurses.
Focus on the
Workplace
Constant change
in the health system challenges the
notion that one nurse can be all
things to all people. Nurses with
varied education and practice
competencies bring different skills
to patient care, and they must be
able to practice to the fullest
potential of these capabilities. To
compete as attractive professional
destinations, practice environments
must recognize and reward these
differences by defining nurses'
roles, and by utilizing and
compensating nurses according to
their different educational
preparation and competencies.
The nature of
the care environment in which they
practice is another significant
contributing factor to the
difficulty in recruiting and
retaining registered nurses.
Although low pay rates continue to
be cited by nurses as a professional
drawback, surveys indicate that the
leading factors given for turnover
in the nursing profession are
workplace issues. A 1999 study by
William Mercer, Inc. found the
primary reason for nurse turnover is
"increased market demand"
exacerbated by underlying causes
such as "dissatisfaction with the
job, the supervisor or career
prospects." The second most cited
reason for turnover in the nursing
profession according to Mercer was
"workload and staffing." These are
fundamental problems that stand
separate from the issues related to
the supply and demand for nursing
services. Unless issues related to
the care environment are addressed,
strategies to increase the overall
supply of nurses will not be
successful.
Strategies
for the Future
The Tri-Council
recognizes that others have voiced
concerns about the nursing shortage
and that many organizations have
identified gaps, made
recommendations and implemented
strategies to address nursing
workforce issues. Many of these
recommendations are relevant today.
However, in
order to encourage the development
and deployment of nursing personnel
with skills appropriate to the
health care system, the public,
policy makers and the profession
must engage in ongoing long-term
workforce planning, regardless of
the perceived or real pressures
related to the short-term demand for
nursing services. Without measures
to reverse the trends discussed
above, the nation is in danger of
experiencing serious breakdowns in
the health care system. Strategies
to recruit and retain are costly and
must be done with some assurance
that these efforts will be
accompanied by specific strategies
to overcome workforce issues that
discourage long-term commitment to a
career in nursing. Therefore, the
following recommendations are made
to address a number of concerns.
Education
-
Develop
career progression initiatives
to:
-
Move
nursing graduates through
graduate studies more
rapidly;
-
Identify
the range of options
available beyond the
entry-level role such as
faculty, researcher and
administrator.
-
Institute an
education and practice system to
promote more equitable
compensation in the health care
community based on a better
understanding of the educational
preparation required for
different health care roles.
-
Support
health care employers to create
and sustain staff development
programs and lifelong learning
for continued competence.
-
Reach out to
youth (ages 12 to 18) through
counselors, youth organizations,
schools and other outlets to
promote recruitment of a
younger, more diverse population
of nursing students.
Work
Environment
-
Implement
specific strategies to retain
experienced nurses in the
provision of direct patient
care, such as:
-
Introducing greater
flexibility into work
environment structure and
scheduling programs;
-
Rewarding experienced nurses
for serving as mentors
and/or preceptors for new
registered nurses;
-
Implementing appropriate
salary and benefit programs.
-
Create a
partnership environment that
advances the practice of nursing
by:
-
Establishing appropriate
management structures within
the health care system;
-
Ensuring
adequate nurse staffing; and
-
Providing nurses with
sufficient autonomy over
their practice in all
settings.
-
Redesign
work to enable an aging
workforce to remain active in
direct care roles.
Legislation and
Regulation
-
Advocate for
increased nursing education
funding under Title VIII of the
Public Health Service Act and
other publicly funded
initiatives to improve the
capacity and resources for
education of an appropriate
nursing workforce.
-
Advocate for
better identification of
registered nursing services
within Medicare, Medicaid and
other reimbursement systems.
Technology,
Research and Data Collection
-
Investigate
the potential for using
technological advances to
enhance the capacity of a
reduced nursing workforce.
-
Support
workforce planning by the
Division of Nursing and other
public or private organizations
to develop models for health
workforce planning that consider
both the need and demand for
nursing services.
-
Promote
consistent data collection at
the national, state and local
level to account for variations
at each level to enable
appropriate workforce planning
for registered nurses.
REFERENCES
American
Association of Colleges of Nursing.
(1998). "As Registered Nurses Age,
Nursing Schools Seek To Expand the
Pool of Younger Faculty." Issue
Bulletin. Washington, DC: Author.
American Association of Colleges of
Nursing. (1999). "Faculty Shortages
Intensify Nation's Nursing Deficit."
Issue Bulletin. Washington, DC:
Author.
American Organization of Nurse
Executives. (2000). "Perspectives on
the Nursing Shortage: A Blueprint
for Action". Monograph Series.
Washington, DC.
Moses, E.
(1998). "The Registered Nurse
Population: Findings From the
National Sample Survey of Registered
Nurses 1996." Health Resources and
Services Administration, Department
of Health and Human Services.
Washington, DC.
National
Advisory Council on Nurse Education
and Practice. (1996). "Report to the
Secretary of the Department of
Health and Human Services on the
Basic Registered Nurse Workforce."
Health Resources and Services
Administration, Bureau of Health
Professions, Division of Nursing,
Rockville, MD: Author.
National Council
of State Boards of Nursing, Inc.
(1994, 1995, 1996, 1997, 1998,
1999). "Licensure and Examination
Statistics." Chicago, IL: Author.
National League
for Nursing. (2000). Unpublished
Data. New York, NY.
National Opinion
Research Data. (1996). Chicago, IL:
Author.
National
Research Council. (1996). "Survey of
Earned Doctorates." Washington, DC:
Author.
William M.
Mercer Inc. (1999) "Attracting and
Retaining Registered Nurses - Survey
Results." Chicago, IL.
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