The nursing shortage: a crisis in health care. (Health Policy Update).

There are more than 2.6 million nurses in the United States. For the first time, estimates show that growth in the profession is insufficient to keep up with the projected demand and shortages are already becoming evident throughout the county. Technological advances in medical care and changes in the provision of care have led to a revolution in the nursing field and opportunities for nurses have expanded beyond the traditional roles of primary nursing and nurse managers. These opportunities include advanced practice nursing, quality assurance, risk management, utilization review, and infection control.

What is even more important is that nurses participate in the senior most elements of health care management as well, in such roles as chief executive officer or chief operating officer. As a result, the impact of nursing has increased in all areas of the health care system. Unfortunately, the supply of nurses has not keep up with the demand and there is a growing shortage in the number of well-trained, qualified nurses.

The causes

Several factors have contributed to the current shortage (please see Table 1). Nursing is a profession dominated by women--over 90 percent of nurses are women. As employment opportunities in other industries have opened up, fewer women have pursued nursing careers.

Geraldine Bednash, PhD, RN, a noted nursing researcher stated, "The most important factors contributing to the aging of the nursing workforce are a long-term trend of declining interest in nursing by women who today enjoy a wide choice of career opportunities..." (1) More and more women are choosing careers in business, law, education, science, and technology. Furthermore, after working the wards for 20 years, nurses in their forties have ascended the medical corporate ladder. Today more nurses opt for less patient care and more paperwork. They become supervisors, administrators, and nursing directors or they retire from health care and, while still young, go on to second careers.

The nursing workforce is aging as well. Experts predict "the average age of nurses will be 45.5 years in the next ten years, an increase of 3.5 years over the current age." (1) Subsequently, "over the next ten years, this trend will lead to further aging of the registered nurse (RN) workforce because the largest cohorts of RNs will be between age 50 and 69 years." (2) The bottom line for the American health care system? "The number of the nation's full-time equivalent registered nurses will peak around the year 2007, but decline steadily afterwards." (2) Because of the central role nursing plays, the potential impact of this shortage on the quality of patient care in hospitals and nursing homes across the nation is alarming.

The aging of the nursing workforce is also evident in the number of nurse educators--they are almost ten years older than their clinical counterparts, raising the specter of an inadequate pool of nurse educators to train a newly recruited workforce.

Managed care has been reported to contribute to the shortage. Sicker, more complex patients have resulted in larger, more intense caseloads and greater responsibility. Many in the nursing field believe that this has contributed to a greater degree of "burn out." This has become a quality issue of great concern to policymakers.

With hospital downsizing, managed care, and an emphasis on outpatient services, the medical workplace has become less dependent on nurses to staff facilities. Nurses complain "that employment opportunities are disappearing rapidly in acute care hospitals where historically two-thirds of all RNs have been employed." (3) The decline in hospital employment opportunities is directly related to the shift of care into non-acute and outpatient settings. Also, the shift from RNs and licensed practical nurses (LPN) to less trained support personnel is viewed by many as further decreasing the quality of care.

Managed care has also "adversely affected the employment and earnings of nurses nationwide." (3) As managed care organizations and health maintenance organizations trimmed costs for care, they reduced the salaries of caregivers. "Hospital corporations increasingly turned to squeezing labor costs--and nursing care in particular, their main source of expenditures." (4) Consequently, nurses' wages have stalled and in some markets are less than those of other professions. The average salaries for staff RNs in Florida, for example, ranged from $29,182 to $43,908 in 1999. (5)

Registered nurses accounted for the first wave of layoffs by managed care organizations and restructured hospitals. In Northern California between 1994 and 1997, "Kaiser Permanente alone laid off 1,600 RNs." (4) Evaluations of the recent data and surveys has shown that "RNs can expect little employment growth in hospitals, a deceleration of employment growth in home health, and a continued gradual decline in wages over the next few years." (6) Concerns about compensation, increased caseloads, and hospital downsizing have significantly affected the numbers of today's nursing workforce.

Strategies to turn the tide

In a number of states across the nation, health care providers, hospitals, colleges, and universities are trying to devise incentive programs to attract high school and college students into nursing education/training programs. According to the American Association of Colleges of Nursing (AACN), enrollments in "bachelor's degree nursing programs have declined consistently...dropping 4.6 percent in 1999 alone." (6)

Furthermore, "while enrollments in master's programs grew steadily through most of the 1990's...they too have experienced slight declines in the past two years." (6) To change the trend, institutions are offering scholarships, tuition-free courses, and signing bonuses to nursing school candidates. Creative recruitment practices "range from movie theatre advertising to innovative partnerships with hospitals" (6) to entice students to sign up for nursing courses.

Health care facilities including hospitals, nursing homes, and home health care providers are offering flexible work schedules, cash bonuses for referrals, sign on bonuses, education credits, and lucrative retirement plans. Promotional opportunities/career advancements to attract more men and non-English speaking students to a career in nursing are also being used.

Several states have put together workgroups to address this issue. Clearly, the first steps include policy initiatives that:

* Slow the exodus of individuals from the field

* Make nursing more competitive with other fields

* Enhance early career decisions in the middle school and high school levels by working with school counselors

* Enhance the nursing academic community

Conclusion

More complex steps will need to be taken to ensure stability in the nursing workforce over time and to prevent shortages from happening again. Initially, these actions will increase costs to health care systems. But failure to address this now will result in a lower quality of care. Working with nursing leadership, physician executives can make a difference. This is an important problem that is not going to go away.

Health policymakers need to work with nursing leaders to devise dramatic, creative mechanisms to increase the number of well-educated, properly trained nurses throughout the health care industry nationwide. By starting now, we can ensure an adequate supply in the future.

Table 1

Causes of the Nursing Shortage

Aging workforce

Reductions in nursing students

Expanding non-medical job opportunities for women

Sicker patient population with expanding caseloads

Expanding clinical and non-clinical opportunities
 (for example, senior management, infection control,
 nurse clinicians, case management, and home health)

Downsizing of the acute care system due to managed care

Compensation concerns

Early retirements

Georges C. Benjamin, MD, FACP

Note

The stated views are those of the author and do not represent those of the State of Maryland or the Department of Health and Mental Hygiene.

References

(1.) Bednash, G. The Decreasing Supply or Registered Nurses. Journal of the American Medical Association. 2000; 283(22).

(2.) Buerhaus. P. Implications or an Aging Registered Nurse Workforce. Journal of the American Medical Association. 2000; 283 (22).

(3.) Buerhaus, P. Trouble in the Nurse Labor Market? Recent Trends and Future Outlook. Health Affairs. 1999; 18(1).

(4.) DeMoro. D. Engineering a Crisis: How Hospitals created a Shortage or Nurses. Revolution: The Journal for RNs and Patient Nurses. 2000; 1(2).

(5.) Florida Hospital Association, "Non-Management Salary Survey Report May 1999, 1999 Fact Sheet, Supply or Nurses In Florida."

(6.) Mezibov. D. (Editor), "Amid Nursing Shortages. Schools Employ Strategies to Boost Enrollment." American Association or Colleges of Nursing. AACN Issue Bulletin, June 2000.

Georges Benjamin, MD, FACP, is the Secretary of the Department of Health and Mental Hygiene in Maryland, Baltimore. He can be reached by calling 410/767-6505 or via email at [e-mail].