Nursing the Trends

The current nursing shortage is a double-edged sword. It means staff shortages and exhausting shifts for nurses—both of which compromise patient outcomes. 1 But it also means that nurses’ salaries are at an all-time high and employers are offering new incentives and benefits, flexible scheduling, and chances for nurses to participate meaningfully in decisions affecting their work environments, as well as patient care. There are also unprecedented opportunities for advanced practice nurses (APNs) and specialty nurses. This article describes current and projected numbers of nurses in the workforce, the demand for registered nurses, the effect nursing shortages have on patient care, and anticipated employment opportunities for RNs in 2004. NURSING THE NUMBERS Every four years since the mid-1970s, the Bureau of Health Professions of the U.S. Department of Health and Human Services has provided the most extensive and comprehensive statistics available on RNs currently licensed to practice in the United States. The following data are from the most recent survey, conducted in 2000, available online at http://bhpr.hrsa.gov/healthworkforce/reports/rnsurvey/rnss1.htm. 2 How many are we? According to the survey, the estimated number of licensed RNs in the United States is 2,696,540. The total number of RNs employed in nursing is 2,201,813. Of the total number of employed licensed RNs, 71.6% work full time, compared with 28.4% working part time. How old are we? As a workforce, we are aging. The average age of an RN is 45.2; the average age in 1996 was 44.3 years. In 1980, 52.9% of RNs were under 40. According to the 2000 data, 31.7% are under 40. A recent exhaustive study by Buerhaus and colleagues in the Journal of the American Medical Association predicted that the total number of equivalent RNs per capita working full time would peak around the year 2007 and decline steadily thereafter as the largest cohorts of RNs retire. 3 By 2020, according to the study, the RN workforce will be roughly the same size as it is now, which will be 20% below projected demand. The study found that the main reason for the older workforce is a decline in the number of young women choosing nursing as a career since 1980. How have we been prepared? During the past 20 years, entry-level nursing education has shifted from diploma programs to associate’s or bachelor’s degree programs. In 1980, 60% of licensed RNs had received their basic nursing education through diploma programs, compared with 30% in 2000. In 1980, 19% of nurses graduated from associate’s degree programs, compared with 40% in 2000; 17% had bachelor’s degrees in 1980, compared with 29% in 2000. The net effect of these changes is that nurses are spending less time on their entry-level education. Even though the number of bachelor’s and master’s programs is increasing, a far greater increase is seen in the number of nurses in associate’s degree programs than in the number of nurses in hospital programs. Associate’s degree programs take two years to complete; hospital programs take three.FIGUREFigure 1:: Nurses’ Entry-Level Education, 1980 vs. 2000The number of two-year community colleges with RN programs increased dramatically in the 1960s and has steadily risen since. At the same time, the number of three-year hospital diploma programs has been decreasing. Not only was the demand greater for the two-year programs, but hospitals were forced by harsh economic forces—brought about by managed care systems—to close unprofitable programs. One result of these shifting trends in nursing education is that, according to Donley and Flaherty, nurses are undereducated when compared with other members of the health care team. This is a real problem, as they view it, because “undereducated members of the health care team rarely sit at policy tables or are invited to participate as members of governing boards. Consequently, there is little opportunity for the majority of practicing nurses to engage in clinical or health care policy.”4 On the bright side, more nurses than ever are pursuing postgraduate education. In 1980, 5% of the 1,662,382 RNs had a master’s or doctoral degree. According to the last survey, 10% of nearly 2.7 million RNs have such degrees. These statistics also reflect the dramatic increase in the number of master’s degree programs in nursing available to those who have bachelor’s degrees in areas other than nursing. The influx of people with baccalaureates from other fields into nursing increases our diversity and broadens our perspective. Where do we work? Of today’s employed RNs, 59.1% work in hospitals, 18.2% in public and community health (including occupational and school health settings), 9.5% in ambulatory care, and 6.9% work in nursing homes and extended-care facilities. The remainder of nurses work in nursing education and other settings (such as prisons, jails, and insurance companies). The settings that saw the largest increase in number of RNs were the public and community health sectors, including state health departments, community health centers, and visiting nursing services. How much do we make? The Bureau of Health Professions survey measures average RN earnings through two indices: the actual average earnings of RNs employed full time and the “real” average earnings (actual spending power) of those RNs. The actual average annual salary of a full-time RN is at an all-time high of $46,782—it was $17,398 in 1980. 5 However, real compensation amounts to only $23,369 when changes in the purchasing power of the dollar are taken into account through the consumer price index. Real salaries have been about the same since 1992 (see Figure 2, page 28).Figure 2.: Annual Nurses’ Salaries, Actual vs. ‘Real’How many of us work in advanced practice? The number of nurses prepared to be nurse practitioners, clinical nurse specialists, nurse midwives, or nurse anesthetists rose to 196,279 by 2000 (7.3% of RNs), up from 6.3% of RNs in 1996. Of nurses working in advanced practice, the majority are nurse practitioners; the next largest group is clinical nurse specialists. These two together, including those trained for both jobs, comprise approximately 80% of all APNs. Nurse midwives account for 4.7% of APNs (up from 1996), and nurse anesthetists account for 15.2% (slightly down from 1996). NURSING THE DEMAND Today there are more than 126,000 unfilled nursing positions—around 7% below the workforce requirement. 1 The nursing shortage is expected to continue. A recent workforce study by the Bureau of Health Professions projects a 12% deficit in nurses for 2010, a 20% deficit by 2015, and a staggering 29% shortage of RNs in 2020. 6 Advances in medical technology and pharmaceuticals as well as healthy lifestyle choices have resulted in “the graying of America,” as life expectancy increases and quality of life improves. The current number of unfilled nursing positions is a frightening concept when the number of nurses needed to care for the 78 million baby boomers is considered, especially when they reach age 65 in a few years and begin placing unprecedented demands on the health care system. WHY THE SHORTAGE? Why, if there’s job security and decent pay, is there such a profound shortage of nurses? The reasons are numerous and complex. A 20-year buildup of conditions created the “perfect storm”—our current protracted, calamitous nursing shortage. Certain economic pressures, starting with the introduction of the managed care system in the 1980s and continuing with hospital mergers in the 1990s, necessitated a rethinking of how care was delivered. This transformed health care system transferred much of inpatient care to the outpatient setting and to patients’ homes. This shift is reflected in the dramatic decrease in the average hospital length of stay during the last two decades. In 1980, the average length of stay was 7.3 days. 7 In 2000, this average had fallen to 4.9 days. 8 What this means for the nearly 60% of RNs who work in hospitals is that today’s patients are sicker than in the past, requiring more intense nursing care. Another factor that has influenced today’s shortage was a 1995 report by a blue-ribbon commission funded by the Pew Charitable Trusts. The report warned that hospital mergers would close the doors of almost 50% of our nation’s hospitals by 2000, which would mean a loss of 60% of hospital beds and a surplus of 200,000 to 300,000 nurses. 9 The Pew prediction was wrong, and far fewer hospitals closed than anticipated, but the report left its mark on history by discouraging young people from entering the nursing field. The reshaping of health care by market forces has meant fewer hospital resources for nursing. Dealing with intense assignments and extra shifts (including mandatory overtime), nurses are overworked and have become stressed, burned out, and left with little job satisfaction; all these factors contribute to the nursing shortage. Furthermore, as nurses get older and retire, more people are leaving than entering the profession, even with increased enrollments in schools of nursing. Women account for 95% of nurses, yet young women are not choosing to become nurses as frequently as they once did. This is leading to a further reduction in the number of nurses. But at the same time that nursing enrollment is down, the number of women entering medicine is increasing. Medical schools now boast a 50:50 female-to-male enrollment ratio (see www.aamc.org/data/facts/famg52002a.htm for information). We don’t have the capacity to educate as many nurses as we used to, as evidenced by a far higher number of applicants than enrollees. Gail Collins wrote about the shortage in a 2001 New York Times article: “[Nurses are] unhappy, and they’re spreading the word. . . . Management has a right to be efficient and demand results, as long as everybody remembers that the nurses of the future have a right to sign up for dentistry or accounting.”10 NURSING THE EFFECTS According to a white paper by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the nursing shortage is “a prescription for danger.”1 The JCAHO report shows that the shortage contributed to nearly a quarter of the unanticipated problems in hospitals that resulted in patient death or injury, citing insufficient numbers of nurses as a reason for those cases. The JCAHO used its “sentinel event” reporting system (a computer database that includes 1,609 reports of patient deaths and injuries between 1996 and the report date), as well as detailed explanations from hospitals to generate these results. 1 The paucity of nurses affects more than patient injuries and deaths. It contributes to some of the thorniest problems in health care today. It’s a major factor in ED overcrowding and “diversions,” cancellation of elective surgeries, discontinuation of clinical services, and limitations in the health care system’s ability to respond to mass casualties. Ninety percent of nursing homes report that they do not have enough nurses to provide even the most basic level of care, and some home health care agencies are being forced to refuse new admissions. 1 Reversing the nursing shortage will not be simple, but it’s fixable, and it’s up to us. It will take a community—nurse executives, hospital leadership, policymakers, schools of nursing, physicians, creditors, private industry, and nurses. The JCAHO report calls for reforms to the nursing education system and for the federal government to tie Medicaid and Medicare payments to a hospital’s improvement in nursing care and nurses’ work environments. The nursing profession. Perhaps the greatest hope for the alleviation of the nursing shortage is the Magnet Recognition Program, the brainchild of the American Nurses Credentialing Center (ANCC) (a subsidiary of the ANA). Magnet hospitals are desirable settings for RNs and have better patient outcomes than other hospitals; this gives them an edge in recruiting and retaining nurses in a tough market. The Magnet Recognition Program came about in response to the severe shortage of the early 1980s. The American Academy of Nursing, the ANA, and a group of nurse executives were looking to combat that shortage and decided to conduct a national study to identify those hospitals that attracted and retained nurses. That study led to 41 hospitals receiving the designation, “Magnet hospital.”11 In the early 1990s the ANA, through the ANCC, formalized the program to acknowledge excellence in nursing. It’s a form of external peer review available to all hospitals and health care organizations. The Magnet designation is awarded according to 14 standards of nursing: high-quality care, strong nursing leadership (including a nursing staff that makes decisions about clinical care and its own practice), dynamic performance improvement, large number of APNs, heavy involvement on the part of nurses with the community, and a high degree of interdisciplinary collaboration. Organizations are evaluated in a process that consists of several stages, including documentation of attainment of the 14 standards and on-site review. Currently 85 organizations in the United States and Britain have been awarded this nursing seal of approval. Fewer than 1% of hospitals have achieved this rigorously determined certification. 12 Magnet recertification is required every four years. Studies by Linda H. Aiken, PhD, RN, FRCN, FAAN, and others have demonstrated the value of the program in terms of fostering both positive patient outcomes and satisfactory work environments for nurses. 11,13 Policymakers. The nursing shortage has certainly received the attention of the U.S. media. Policymakers at the state and national levels have watched the news, read newspapers, listened to constituents, and begun to pass legislation to alleviate the shortage. In mid-2002 the Nurse Reinvestment Act was passed by Congress and signed by President Bush. This law modified funding for existing nursing programs—including ones for advanced practice nursing, basic nursing (nurse education, practice, and retention), nursing workforce diversity, and loan repayment and scholarship—and created geriatric care training and faculty loan programs. For fiscal year 2003, Congress appropriated a total of $113 million for all nursing programs—an overall increase of $20 million over fiscal year 2002—but still less than the recommended $250 million. 14 Most states have begun to address the shortage through legislation and funding to expand nursing. Some states have passed laws to improve the for nurse The Association and the Nurses Association with the of which has to nurse in hospitals are now also required to form with from nurses. The of signed in all hospitals in by 2004. 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