In a military town, Suzanne Purdy, MBA, RN,
partially handles rapid staff turnover by hiring
married registry nurses. The benefits of a full-time
job aren’t as much of a lure for them, she said, if
their military spouses supply the medical/dental
coverage.
But the expense and stress of constantly training
new part-time registry nurses takes its toll on her.
Out of necessity, Purdy, vice president for patient
care at Paradise Valley Hospital in San Diego, a
Christian-owned, nonprofit community hospital with
302 beds, also hires new grads for positions in the
definitive observation unit.
In the past, Purdy would have held out for more
experienced nurses. Some of the new hires do come
from skilled nursing environments but haven’t worked
in acute care for a while, she said. They usually
require special refresher education and clinical
precepting to return to the bedside. "Then what may
happen is they’ll leave," she said.
Studies indicate that loyalty is diminishing among
Gen-Y and Gen-X nurses, she added. Job-hopping,
largely frowned upon by baby boomer nurses, is the
norm among their younger cohorts, who often stay
exactly as long as their $3,000 to $5,000 signing
bonuses say they must, Purdy said. "From my
experience, the nursing shortage is acute–extremely
acute," she said.
The alarm sounds
Purdy is far from alone. News reports from across
the country paint an alarming picture of an acute
worldwide nursing shortage that promises to become
much worse in the years ahead.
Knowledge of the problem saturates most nurses, but
solutions still may look murky. Ominous results of
the latest National Sample Survey of Registered
Nurses show the supply of nurses–thoroughly reported
as insufficient–will slow even further. Sigma Theta
Tau International Honor Society of Nursing calls the
shortage a major threat to the future of the world’s
health care system. It’s not just a U.S. crisis.
Australia, Canada, and parts of Europe and Asia also
report problems.
Ominous effects
The most convincing evidence of the nursing shortage
is the rapidly rising vacancy rates in every region
of the country.
Some hospitals are canceling nonurgent surgeries,
closing beds or units and diverting emergency room
patients. As a result, some hospitals and nursing
homes are unable to admit patients and some home
care agencies are unable to take on new clients.
The Texas Hospital Association, for instance,
reports rising RN vacancy rates across the state
that range from 10 percent to as high as 18 percent
in some specialty areas.
In the Dallas/Fort Worth area, the RN vacancy rate
is 10.4 percent, while the vacancy rate among RNs
working in intensive care units is an alarming 16.9
percent (up from 12.7 percent in 1999). Generally,
according to the association, vacancy rates of 9
percent or above are thought to indicate a
significant shortage.
In November, nursing shortages forced Johns Hopkins
Hospital in Baltimore to leave 10 percent of its
surgical beds unfilled, delaying or canceling some
surgeries.
In February, Saint Elizabeth Regional Medical Center
in Lincoln, Neb., reported an 11 percent vacancy
rate in its 435 registered nursing and licensed
practical nursing positions.
Why now?
Although nursing shortages have occurred before,
today’s is different because it is being driven not
just by a diminishing supply of new talent entering
the profession, but by a growing demand for health
care as the baby boom generation approaches its
golden years.
The latest numbers from the American Association of
Colleges of Nursing indicate that enrollments in
five-year baccalaureate nursing schools dropped 16.6
percent during the past five years, from 72,452 in
1996 to 60,443 in 2000. Within 10 years, 40 percent
of working RNs will be 50 or older, according to
Sigma Theta Tau.
As those RNs eventually retire, the supply of
working RNs is projected to be 20 percent below
requirements by 2020.
Today’s shortage also occurs at a time when nursing
has lost some of its luster as a career opportunity,
partly because nursing is a traditionally female
profession and today’s women have more options than
they did before. Women graduating from high school
in the latter part of the 1980s and during the 1990s
were 35 percent less likely to become RNs compared
to women in the 1970s, according to the Texas
Hospital Association.
What’s more, experts say changes in the delivery of
health care in a managed care environment have
caused some nurses to become frustrated. Their
complaints have discouraged newcomers from joining
the profession. In a survey released last month by
the American Nurses Association, 54 percent said
they would not recommend their profession to their
children or their friends.
The ANA survey found that 75 percent felt the
quality of nursing care where they worked had
declined during the past two years. A majority, or
56 percent of the 7,299 nurses surveyed, said they
had less time to care for patients. Moreover, 40
percent said they would worry about sending a family
member or someone close to them to be cared for at
the facility where they work.
The shortage is far from universal at this stage,
however. It tends to be felt hardest in isolated
rural areas, depressed urban environments and key
specialty areas. The numbers indicate that the
shortage also is more likely to be felt in Western
and Southern states than it is in the East and
Midwest.
Solutions on tap
Nursing schools, the obvious route to replenish the
pipeline, have a hard time funding adequate numbers
of enrollees. Judy Papenhausen, Ph.D., MSN,
chairwoman of the department of nursing at
California State University, Los Angeles, said new
enrollees in the department have increased from 50
to 70 per year. She’d like to double those numbers,
but funds are scarce.
The requisite low student-to-teacher ratios in
nursing schools mean costs are much higher than in
some other departments, such as English literature.
"With more money from the Chancellor’s office or
from the federal government, the schools could admit
another whole class," Papenhausen said.
Losing good nurses to other states means that
recruitment and retention strategies at St. Alexius
Medical Center in Bismarck, N.D., must focus on
graduates of the two nursing schools in town.
Linda Knodel, MHA, RN, assistant
administrator/director of nursing at St. Alexius,
said the hospital tries to keep the local graduates,
known for their good work ethic, from accepting
offers elsewhere by offering scholarships, serving
as guest faculty at the local nursing schools,
running job shadowing programs for junior and senior
nursing students, providing scholarships for junior
and senior students, and offering competitive wages.
Purdy said her adjusted hiring methods might include
using a different skill mix to avoid burning out
existing staff nurses.
"My hospital is all RNs, but I’m evaluating using
LVNs or CNAs as nurse extenders. Then I always
encourage them to move up their credentials a
notch," she said.
Given the shortage, she said it’s not realistic to
think she can hire all BSNs with clinical experience
and the intent to stay.
Underlying causes
According to the newly released preliminary findings
of the National Sample Survey of Registered Nurses,
California trails only Nevada in the number of
registered nurses per 100,000 population. The
national average is 782 employed RNs per 100,000
population.
When the survey was conducted last March, California
had 544 employed RNs per 100,000 and Nevada had 520.
On the top end of the scale, the District of
Columbia had 1,675 employed RNs per 100,000
population, while Massachusetts had 1,194 and South
Dakota had 1,128.
So while no state may be immune from the shortage,
especially in key specialty areas, the numbers have
led researchers to conclude that some states have
more work to do–and more to fear–than others. In
California, for example, researchers estimate that
the state will face a shortage of 25,000 RNs within
the next five years.
Survey results
Preliminary results of the National Sample Survey
give nurses a clear idea of approaching patterns in
the crisis.
"We have seen a decline in enrollments and
graduations. Nurses are getting older and leaving
the workplace, and we’re seeing a salary issue. If
you look at the salary table, there hasn’t been much
growth on a real scale since 1992," said Denise
Geolot, Ph.D., RN, FAAN, director of the Division of
Nursing in the Bureau of Health Professions, part of
the Health Resources and Services Administration in
Washington, D.C., which released the preliminary
survey results in February. The HRSA falls under the
umbrella of the Department of Health and Human
Services.
"The apex of the age curve has moved, so we have
68.3 percent of nurses over 40, which is a real
concern. We have a small percentage under age 30,"
Geolot said.
The supply of nurses has increased during the past
four years, Geolot said, but at a slower rate than
in the past. It’s the lowest increase since 1977.
That reflects the lower number of grads entering the
workforce vs. a larger body of exiting nurses.
But, Geolot said, "We’re pleased that more men are
entering. Male nurses made up 5.4 percent of the
workforce in 2000, whereas in 1996, they made up 4.9
percent of it."
The number of racial and ethnic minorities in
nursing also has increased, she said. In 1996, they
made up 10.3 percent of the workforce vs. 12.3
percent in 2000. Still, Geolot said, those numbers
are lower than she’d like to see.
HRSA will funnel the data from the National Sample
Survey into a forecasting model to be released this
summer, which will further help predict nursing
supply and requirements in 2010, Geolot said.
The Web site for the survey is www.bhpr.hrsa.gov.
Since 1977, HRSA has–every four years–released
extensive and comprehensive sources of statistics on
characteristics of all nurses with current licenses
to practice, Geolot said. The 2000 survey went out
to 54,000 nurses. Of those, 4,520 were excluded
because of duplicate licensure, so the survey polled
a total of 49,480 nurses, or 72 percent.
Of course, Geolot said, there’s lots of interest in
looking into solutions about the future; many states
are investigating strategies and congressional
hearings lately address legislation toward reducing
the shortage.
Improving the image
The good news is that much already is being done in
an effort to reverse the trend.
In Massachusetts, unions and employers are pushing
for the Clara Barton Act proposed by state Sen.
Richard Moore, D-Uxbridge, who heads the
Legislature’s joint committee on health care. Named
for the Massachusetts nurse who helped to
professionalize nursing, the bill would
provide $25,000 starting bonuses over several years
to new nurses in the top 15 percent of their
classes, similar to bonuses given to teachers.
In Nebraska, Saint Elizabeth Regional Medical Center
instituted a three-part program for new nurses in
August. It includes a preceptor program to help new
hires with their clinical and technical skills, a
mentoring program to help them adjust to hospital
culture and personalities and a commitment program
with financial incentives ranging from $500 to
$1,500 to stay for three years.
In Texas, state Sen. Mike Moncrief, D-Forth Worth,
and Rep. Patricia Gray, D-Galveston, have introduced
the Nurse Shortage Reduction Act of 2001. The
legislation, among other things, would double
nursing school capacity during the next five years
in a state where thousands of qualified applicants
are being turned away.
Two years ago, according to the Texas Hospital
Association, a lack of budgeted faculty positions
was the primary factor in forcing nursing schools to
deny admission to 2,225 qualified applicants to
associate degree or diploma programs, and to 788
qualified applicants to baccalaureate and master’s
programs.
Dorel Harms, RN, vice president of professional
services at the California Healthcare Association,
emphasized late last year the importance of
recruitment at nursing schools. The California
Nursing Outcomes Coalition is addressing the images
of nursing and how nurses are recruited, Harms said.
Patricia McFarland, MN, RN, executive director of
the Association of California Nurse Leaders, said
late last year, "We have to do an imaging campaign.
We need to work with young people to dispel a lot of
myths about nursing. We need to attempt to bring
[prospective students] in before the freshman year
in high school.
"I think we need to educate counselors, as well. The
role of a nurse is to assess, evaluate and plan
patient care. It’s a distinct role."
Still, solutions won’t be easy.
"This is not just another cyclical shortage of
nurses that can be rapidly cured by paying nurses
higher wages and enrolling more students in nursing
schools," said Edward O’Neil, Ph.D., MPA, director
of the Center for the Health Professions as the
University of California, San Francisco.
"The aging of the nursing workforce, the upheaval in
the health care system and the expansion of career
opportunities for women [who make up 94 percent of
the nursing workforce in California] are combining
to produce a chronic shortage of nurses. That
shortage can only be resolved by improving the work
environment for nurses and redefining nursing
practice."
