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.
- 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.
- 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.
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.