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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