Even before last year's Future of Nursing report from the Institute of Medicine highlighted the need for better data on the number of working nurses, people were beginning to pay serious attention to how nurses are counted. Cyclic nursing shortages and surpluses have piqued interest in just how many nurses we have—and how many are needed.
Most of the estimates of nursing supply come from state licensure files. These sources are problematic for various reasons, including the inability to link across states. There's no standard set of data collection questions about nurse employment and, in general, scant information specifying actual site of practice or specialty, except by type of institution or setting. Finally, if nurses don't maintain their licensure—and many who work outside of direct care don't—they aren't captured in these data, even though they may be applying nursing intelligence in their various jobs.
Another source is the National Sample Survey of Registered Nurses, administered every four years by the U.S. Department of Health and Human Services. This survey of a sample of RNs is taken from the same state licensure databases in an elegant sampling design. It inherently has the same limitations as the licensure data, even though the information collected on nurse employment (including RNs who aren't working in nursing) is much richer and could be mined, were there interest.
And there should be.
For a number of years, I worked in a large academic medical center in an arm of the institution's finance department called “Decision Support.” This terrific job took me all over the hospital, seeking data to support evidence-based clinical, financial, and operational decision making. I often stumbled over nurses in odd corners, doing very important work that frequently depended on their knowledge of clinical work and operations, even though their positions might not have required a nursing license.
I found nurses in the revenue department, monitoring payment denials and writing appeals to federal and state agencies. When I started there, the chief counsel of the hospital was a nurse (and a lawyer, of course) who continued to publicly use her nursing knowledge and identity. Nurses made up the entire staff of the care coordination department, the folks who get patients out of the hospital. A nurse was the head of the purchasing department for a time, credited with an uncanny ability to smell snake oil on vendors at 20 paces.
Presently, all of the senior staff of the operations support department are nurses, and they have been enormously influential in smoothing relationships with other departments, so that the hospital's work (much of which, of course, is nursing) can get done.
Nurses run the operating and recovery rooms. And all of the nursing units.
The huge patient safety and quality initiative in our hospital runs on the backs of nurses who are gradually adding “director” to their titles in their specialty areas. Nurses supply the senior leadership in performance improvement, many of them with metaphorical Six Sigma black belts under their scrubs.
Some of these positions require a nursing license and some don't.
Walk through your own medical center, and you'll find the same thing.
Are all nurses counted?
Well-intentioned efforts to get a better grip on nursing work-force issues miss the larger point (and one that I've asserted before): the reason for the existence of the modern health care delivery system is to provide nursing care.
The whole point of counting things, whether it's births or deaths or nurses, is so that people count. Nurses are everywhere—by nursing title and license or not. Person-power counts will always be an incomplete enumeration of the discipline's contributions.