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DRAMATIC
REFORMS REQUIRED TO HEAD OFF CYCLES OF
NURSING SHORTAGES, JAMA EDITORIAL RECOMMENDS
WASHINGTON,
D.C., June 14, 2000 -- Reversing the nation's cycle of nursing
shortages will require reforming the education and credentialing
mechanisms for nursing, restructuring work environments, and
developing systems of care that empower RNs to use their professional
skills, says a commentary in this week's (June 14) issue of
the Journal of the American Medical Association (JAMA).
The commentary
by Geraldine Bednash, PhD, RN, FAAN, executive director of
the American Association of Colleges of Nursing (AACN), accompanies
an article by researcher Peter I. Buerhaus, PhD, RN, of the
Vanderbilt University School of Nursing and colleagues that
forecasts that the number of the nation's full-time equivalent
registered nurses (RNs) will peak around the year 2007, but
decline steadily afterwards. Continued aging of the RN workforce
(whose average age the authors forecast will be 45.4 years
in the next 10 years, an increase of 3.5 years over the current
age) and expanded career opportunities for women (who continue
to make up more than 90 percent of all RNs) are contributing
to the decline.
"Over
the next two decades, this trend will lead to a further aging
of the RN workforce because the largest cohorts of RNs will
be between age 50 and 69 years," Buerhaus and colleagues write.
"By the year 2020, the RN workforce is forecast to be roughly
the same size as it is today, declining nearly 20 percent
below projected RN workforce requirements."
With demand
accelerating for professional nursing care in hospitals, primary
care and other outpatient centers, homes, community health,
and other settings, shorfalls in the RN supply -- already
evident in many cities and regions -- comes at a particularly
inopportune time. Indeed, the researchers write, "the impending
decline in the supply of RNs will come at a time when the
first of 78 million baby boomers begin to retire and enroll
in the Medicare program in 2010."
The researchers'
analysis also "comes on the heels of a recent [AACN] report,
which found that enrollments in entry-level baccalaureate
nursing programs decreased by 4.6 percent in fall 1999 --
the fifth consecutive decline in as many years," Dr. Bednash
writes.
"Attracting
a cadre of young, college-bound students will require reform
in nursing education and in the licensure and certification
mechanisms used to grant practice to RNs with different educational
preparation," she explains. Currently, entry-level nursing
education is offered in four-year baccalaureate programs,
two-year associate-degree programs, and three-year hospital
diploma programs, with graduates receiving the same license
to practice and most often the same entry-level salaries and
positions.
"The continuation
of a system of nursing education that provides graduates of
three different levels of nursing programs with the same license
and role expectations creates a major disincentive to attracting
an adequate supply of baccalaureate-educated nurses for the
future," Dr. Bednash writes. In regional focus groups conducted
by AACN last year on factors associated with declining enrollments
in Bachelor's of Science degree in nursing (BSN) programs,
educators noted consistently that potential BSN students were
"discouraged from pursuing a nursing career by the confusing
array of entry-level options available in the profession,"
and noted that such confusion has led many secondary-school
guidance counselors and students "to not view nursing as an
intellectual endeavor," Dr. Bednash comments.
Moreover,
"at the same time that BSN enrollments are declining, increasing
evidence shows an association between health care quality
and the educational level of nursing staff, the number of
RNs in the clinical setting, and the perceived value placed
on nursing staff by the practice setting." These findings
have been documented in so-called "magnet" hospitals that
have been identified as good places to practice nursing and
are recognized for their ability to attract and retain RNs
in times of shortage. Such facilities, Dr. Bednash notes,
not only give nurses greater status and autonomy over their
own practice and experience lower nurse burnout rates, but
also have been found to have significantly lower mortality
and higher satisfaction in patients than do non-magnet hospitals.
Magnet
hospitals also have a higher proportion of nursing staff prepared
at the baccalaureate level (average 59 percent compared to
34 percent for all hospitals). Indeed, in a 1999 survey of
chief nurse officers at university health systems, respondents
reported their preference for an average of 70 percent of
staff nurses to be prepared with bachelor's degrees, citing
better critical thinking, leadership, and prevention and patient
education skills among BSN graduates compared to nurses with
associate-degree or diploma education. But although 72 percent
of the nurse officers perceived such differences, only 44
percent of their institutions paid differentiated salaries
and only 33 percent applied differentiated role descriptions
based on education.
"Decisions
regarding skill mix, differentiated roles or salaries, and
appropriate regulatory mechanisms to validate knowledge and
competencies should be based on a clear analysis of the health
care system's requirements for nursing care," Dr. Bednash
notes. In particular, "a rationalized model for credentialing
RNs should be based on the different educational preparation
and competencies" achieved in baccalaureate and associate-degree
programs. "This could be implemented through the development
of different licensure examinations for graduates of different
levels of educational preparation," Dr. Bednash writes.
Moreover,
practice environments should be restructured to employ nursing
staff according to their differing educational and patient
care capabilities, Dr. Bednash says. In particular, practice
settings should "allow for the full utilization of the professional-level
competencies of BSN graduates." In addition to the attributes
of magnet hospitals, other hospitals that successfully recruit
and retain nurses over the long-term allow RNs more predictable
and flexible work schedules and use shared governance programs
in which nurses actively participate in decisionmaking on
patient care issues, Dr. Bednash points out.
The stability
of the complex U.S. health care system depends on an available
supply of well-educated nursing personnel, "with clearly defined
roles that are sanctioned through a system of licensure and
certification," Dr. Bednash says. "Recognizing the contributions
of RNs to the delivery of high-quality health care and to
the well-being of those health systems" will provide potential
nursing students with an attractive and rewarding career option.
"Without dramatic reform," she urges, "the shortage of skilled
professional RNs predicted by Buerhaus and colleagues is inevitable."
#
# #
Editor's
Note: The JAMA commentary was written by Dr. Bednash in her
private capacity. No official support or endorsement by the
American Association of Colleges of Nursing is intended or
should be inferred.
The
full text of the commentary by Dr. Bednash and the article
by Dr. Buerhaus are available by contacting the AACN Office
of Public Affairs at 202-463-6930, ext. 227, or by e-mailing
cgazlay@aacn.nche.edu.
The
American Association of Colleges of Nursing is the national
voice for university and four-year-college education programs
in nursing -- the nation's largest health care profession.
Representing more than 500 member schools of nursing at public
and private institutions nationwide, AACN's educational, research,
governmental advocacy, data collection, publications, and
other programs work to establish quality standards for bachelor's-
and graduate-degree nursing education, assist deans and directors
to implement those standards, influence the nursing profession
to improve health care, and promote public support of baccalaureate
and graduate nursing education, research, and practice.
CONTACT: Robert Rosseter
(202) 463-6930, x231
rrosseter@aacn.nche.edu
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