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.FIGURE
The 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).
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
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 workplace. Texas, for example, addressed nurse staffing ratios administratively: The Texas Hospital Association and the Texas Nurses Association worked with the state’s department of health, which has rule-making authority, to change nurse staffing plans in March 2002. Texas hospitals are now also required to form advisory committees with mandated input from front-line nurses. The implementation of California’s safe-staffing law, signed in October 1999, proved difficult; all hospitals in California must comply by January 1, 2004. In 2003, states’ hands were tied when all but a handful of states experienced huge budget shortfalls.
It’s in the best interests of private industry for our nation to have a full and sustainable nursing workforce. One example of private industry aggressively addressing the shortage is Johnson & Johnson’s 2002 advertising campaign, featuring the “dare to care” television spots that portrayed nurses positively. In February 2002 the company launched a two-year, $20 million campaign to attract more people to the nursing profession. The campaign includes scholarships for undergraduate nursing students and nurse educators; television advertisements celebrating nurses and their contributions; national fundraising events to honor excellence in nursing (and to support student and faculty scholarships); and recruitment brochures, posters, and videos for distribution in 20,000 high schools, 1,500 nursing schools, and numerous nursing organizations. In addition, the company launched a Web site, www.discovernursing.com, that offers information on careers in nursing, profiles of 105 nurses across the nation in different jobs, a database of nursing schools, and more than 300 nursing scholarship programs.
It used to be said that nurses “eat their young,” holding recent graduates to very high standards, sometimes resulting in their departure from the profession. Today, most established nurses embrace new nurses as well as traveling nurses. Nurses everywhere feel the strain of the shortage every day, and they’re happy to get what help they can; they show their appreciation.
When I see new graduates I thank them for going into nursing. When I see young people with promise, I ask them if they’re happy with their jobs, and if not, I ask them to think about becoming nurses. Nurses are surely our profession’s best recruiters.
Nurses can further contribute by joining the ANA and state and national professional nursing organizations, as well as labor and nursing specialty organizations. Organized labor plays a critical role in informing the public and policymakers about the needs of the profession. The people in these organizations are the voice of nursing in the halls of state houses and in Congress (sometimes with the help of the media). Nurses must prompt elected officials when nursing bills come up for vote.
NURSING THE OPPORTUNITIES
Both the complexity of health care and the shortage have brought about unprecedented opportunities for nurses. The following are only a few areas of nursing that are innovative and promising.
The need for hospital staff nurses has continued to rise, and the good news in nursing is that nurses can continue to work at the bedside while finding fulfillment. With the move toward Magnet nursing, the bar has been raised for staff-nurse contributions in hospitals. Staff nurses have opportunities that did not exist previously.
I am a staff nurse at a Magnet hospital. Staff nurses are encouraged to participate meaningfully in making decisions that affect patient care and the work environment. I participate in a shared governance structure consisting of a strong chief nurse executive, a nursing executive council, a nursing congress, and eight specialty councils (acute and postacute care, ambulatory care, behavioral health, critical care, emergency care, pediatrics, perinatal care, and surgery). This hospital, like other Magnet hospitals, has a high degree of interdisciplinary collaboration, which I find very rewarding. We have a clinical ladder program that rewards nurses for participating in shared governance and for promoting health on a volunteer basis in the community.
There is also a shortage of nurse faculty members. 15 New money from the government to increase the supply of nurses will have little effect if there aren’t enough teachers. Furthermore, the faculty shortage is a major factor that limits the enrollment in schools of nursing.
The average age of a nursing teacher is 50.2, and with the retirement of this “graying professorate,” the shortage is expected to escalate. 15 (This phenomenon is unique to nursing because nurses are encouraged to gain clinical experience before earning higher degrees and teaching.) A nurse with five years’ solid experience can teach. The opportunity to guide future nurses, combined with the chance to do important research, positions teaching as a very rewarding aspect of nursing. Nurses who want to teach may do well to consider pursuing this goal earlier in their careers.
The remarkable work of the U.S. Human Genome Project is a catalyst for growth in the number of opportunities available to nurses. Coordinated by the Department of Energy and the National Institutes of Health, the project, which began in 1990, has mapped the human genome—the collection of about 35,000 genes and the sequences of the 3 billion base pairs that make up human DNA. 16 The implications for health care are profound. Most health conditions are believed to result from a combination of genetic and environmental influences; the new knowledge will improve the diagnosis and treatment of many illnesses.
Physicians, nurses, and other health care workers, regardless of specialty, will need to integrate new information on genetics into routine practice, especially when explaining responsiveness to treatment and options for care. 17 In response, medicine has developed a specialty, offering services, resources, and education in genetics. For example, where I work in the NICU, when a neonatologist suspects a patient has a particular syndrome but is unsure of which one, another medical specialist—a geneticist—is called in to help identify the syndrome. The geneticist gives a prognosis and the probability that the identified syndrome will occur in other children by the same parents. Staff nurses assist in reducing complex information into practical, understandable terms for families.
As part of genetics teams, nurses provide care in regional genetics networks, private office settings, and specialty genetics clinics, offering assessment, education, counseling, testing, and interpretation of test results. The International Society for Nurses in Genetics (ISONG) (www.globalreferrals.com) offers annual conferences, develops nursing standards of practice, and promotes communication and research on genetics.
Nurses with a master’s degree in nursing may qualify for the credential of APN in genetics. Those with a bachelor’s degree may qualify for the genetics nurse credential. The Genetic Nursing Credentialing Commission (www.geneticnurse.org), a subsidiary of ISONG, recognizes clinical nursing practice with a genetics component by granting credentials based on a portfolio of evidence indicating professional experience.
Advanced practice nursing.
This collective term refers to four specialties: nurse practitioner, clinical nurse specialist, certified nurse midwife, and certified registered nurse anesthetist. The number of APNs has increased. In 2000 there were nearly 200,000 APNs, or 7.3% of the total RN population, up from 6.3% in 1996. 2
The APNs are trained by nurses, credentialed by nurses, regulated by nurses, and most have their own medical malpractice insurance. These highly qualified providers are legally allowed to practice in all 50 states. Certain requirements (being supervised by physicians, for example) vary from state to state and are specified through state nursing and medical practice acts, the rules of nursing and medical boards, and hospital licensing laws. 18
I’ve worked in the same NICU for the past 24 years. In the 1990s, the number of neonatologists and neonatal nurse practitioners (NNPs) in my unit was cut in half. Most of the NNPs here are former NICU staff nurses who have completed advanced training and stayed at our hospital. They write orders (cosigned by a neonatologist) and expertly perform most of the procedures neonatologists perform, such as intubation, insertion of arterial lines, and lumbar punctures. The NNPs have improved the scope of medical care because of their holistic approach to practice and by providing relief to overworked physicians burdened by a neonatologist shortage.
In the hospital where I work, APNs also work in other positions. Certified registered nurse anesthetists work alongside anesthesiologists to deliver anesthesia care. Certified nurse midwives deliver infants in a highly sought-after method of childbirth. Nurse practitioners and clinical nurse specialists make up roughly 80% of APNs and their subspecialties are as varied and numerous as nurses’ interests: community health, gerontology, family practice, medical–surgical, neonatology, pediatrics, perinatal care, psychiatry and mental health, and women’s health. 2
For patients and nurses, medicine is no longer dependent on peripherally inserted short-term catheters for venous access. Implanted, tunneled, and peripherally inserted central catheters (PICCs) are used for long-term venous access, ideal for patients receiving chemotherapy with irritant or vesicant drugs, long-term antibiotic therapy, and total parenteral nutrition. The insertion procedure, which is a sterile technique with placement confirmed by X-ray, requires a medical order.
Where I work in the NICU, nurse clinicians take an eight-hour class from nurses hired by the makers of the neonatal PICCs. After three successful supervised insertions, our institution deems participants competent to insert them. A cadre of “venous-access” nurses is also on call for the rest of the adult and child patients in our hospital network. National certification as an infusion nurse is available through the Infusion Nurses Society (see www.ins1.org for information).
The aging population has increased the demand for gerontology nurses. At the same time, a national movement toward dignifying the death experience has been taking place, giving renewed life to hospice and palliative care.
In the 1990s numerous studies revealed disturbing data about people dying in U.S. hospitals being subjected to unwanted extraordinary measures. Family members were not happy with how their relatives, the patients, were treated at the end of their lives. Then, in 2000, Bill Moyers’s public-television series, On Our Own Terms: Moyers on Dying, opened a dialogue about death and dying. (The show was partially funded by the Robert Wood Johnson foundation, which exerted more cultural influence on health care by providing grants for programs that improved end-of-life care.)
Nurses comprise and manage end-of-life, palliative, and hospice care teams in many settings—at patients’ houses, in hospitals, and elsewhere in the community. Staff nurses whose patients are dying (in NICUs, EDs, ICUs, and long-term care facilities, for example) are finding more enlightened collaboration possible with physicians and other health care workers.
Public health nursing.
The largest increase in RN employment from 1996 to 2000 was in public and community health settings (state health departments, for example). 2 Because of the events of September 11, 2001, it’s possible that more RNs will be employed in this setting. The Centers for Disease Control and Prevention is working with universities, the Department of Homeland Security, and state and local health departments to prepare for and respond to acts of terrorism. Last year, nurses were asked to voluntarily immunize themselves against smallpox—a vaccination not without potentially lethal side effects.
ALWAYS IN DEMAND
The areas discussed here represent only a fraction of the opportunities available to nurses. One thing is clear: Nurses have many choices, and because of the changes brought about by the Magnet program, they can work in settings where they are valued and can positively affect patient care and their own work environments.
The high demand has increased the number of choices for nurses. Travel nursing is in full bloom to fill seasonal needs at hospitals and elsewhere, and this kind of work is a wonderful opportunity for young nurses looking for the right community. As nurse consultants, meanwhile, nurses can work in offices, home care, health care licensing and regulating agencies, schools, legal practices, jails, and insurance and pharmaceutical companies—the list is long.
Qualified nurses are always in demand, as “the primary source of care and support for patients at the most vulnerable points in their lives,” as stated in the JCAHO report. 1 “Nearly every person’s health care experience involves a registered nurse. Birth and death, and all the various forms of care in between, are attended by the knowledge, support, and comfort of nurses.”