Kovner, Christine T. PhD, RN, FAAN; Brewer, Carol S. PhD, RN, FAAN; Fatehi, Farida MS, BDS; Katigbak, Carina PhD, RN
Whether we will see a return of the nursing shortage in the United States anytime soon continues to be debated.1, 2 Regardless, hospitals are dependent on newly licensed RNs (NLRNs). In 2008, 62% of RNs worked in hospitals,3 while according to our own unpublished calculations, 89.1% of NLRNs worked in hospitals in 2009, the closest year for which data were available. With hospital RN turnover rates currently at about 14%, hospitals need NLRNs to replace RNs who retire or leave for another job.4
The passage of the Affordable Care Act (ACA) and the resulting increase in the number of insured people beginning this year will likely increase the demand for RNs in ambulatory care, particularly NPs.5 Changes in the Centers for Medicare and Medicaid Services’ reimbursement system, linking payment to nursing-sensitive outcomes, is also likely to heighten the demand for RNs.6 The economic downturn and the related high unemployment rate may have affected RNs’ work decisions; for example, they may be reluctant to leave jobs if family members are unemployed.7
Much depends on NLRNs but little is known about how their work patterns change over time. Two of us (CTK and CSB) received funding in 2006 for a 10-year national study of NLRNs. The resulting RN Work Project is a longitudinal panel study of issues affecting NLRNs’ careers—their work choices, turnover rates, job satisfaction, and commitment to the profession—with the overall goal of providing data that will aid in balancing RN supply and demand in the health care workforce (for more information, see www.rnworkproject.org).
For this current study we decided to compare the work lives of two cohorts of NLRNs licensed six years apart. Understanding the differences between them could be useful in workforce planning.
Besides changes in reimbursement and rates of unemployment, other changes have been found among NLRN cohorts, including in the types of people who become RNs. For example, men represent a higher percentage of NLRNs now than in the past.8
The supply of NLRNs is increasing. The American Association of Colleges of Nursing reports that applications to bachelor of science in nursing (BSN) programs have consistently increased from 2004 to 2011,1 with enrollment in prelicensure programs increasing by 5.1% from 2010 to 2011.9 In 2011, 4,565 more first-time test takers took the licensing exam than in 2010.10, 11 These increases may be related to the public perception of nursing as a recession-proof profession at a time when the U.S. unemployment rate went from 4.7% in January 2006 to 10% in October 2009, improving only slightly to 8.3% in January 2012.12
Also, enrollments in RN-to-BSN programs increased by 15.8% from 2010 to 2011.9 This trend has been partially influenced by the increasing evidence that RNs with bachelor's degrees make a difference in hospital outcomes, especially in lowered rates of death and failure to rescue.13 It was also influenced by the 2010 Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health, which called for nurses to achieve higher levels of education and to practice as full partners with other health care providers, including physicians.14
Most NLRNs begin their careers working in hospitals,15 although it appears that demand for these RNs may have decreased. Soon after the recession of 2008 began, there were reports of NLRNs having difficulty gaining employment as RNs, perhaps in part because currently employed nurses were working more hours.16-18 It has also been reported that as more young people enter nursing, the number of nurses will grow faster than estimated, resulting in an overall younger workforce and moderating shortages predicted as a result of the retirement of baby-boomer nurses.2 But retaining NLRNs in hospitals has been a challenge. More than 26% of RNs leave their first job within two years of starting,19 although according to our unpublished calculations most get another nursing job. (We determined this using data we had acquired on nurses who left their jobs and what they were doing two years later—one of the advantages of using a panel survey design.)
While many studies of NLRNs employ small or moderate sample sizes,20-22 this study surveyed samples from many states and builds on a previous study that compared a cohort of NLRNs who were licensed for the first time in 2004–05 with a second cohort who were licensed in 2007–08.7 That prior comparison found significant differences in NLRNs’ perceptions of job opportunities available (lower for the 2007–08 cohort) and in their intention to stay at their current job (higher for the 2007–08 cohort), which has implications for health care management and policy.
To continue to monitor differences over time, here we compared a subset of the 2004–05 cohort with a new 2010–11 cohort.
Sample. The first NLRN cohort was a subset of a group of RNs licensed for the first time between August 1, 2004, and July 31, 2005, and surveyed via U.S. mail in 2006. This subset was licensed in one of 23 geographic areas within 14 states (Alabama, Kentucky, Maryland, Michigan, Nevada, New Jersey, North Carolina, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, and West Virginia). The second group consisted of RNs licensed between August 1, 2010, and July 31, 2011, in the same geographic areas. This later cohort was surveyed by U.S. mail in 2012. For both cohorts, we excluded any RN who had practiced outside the country prior to U.S. licensure. For more details about the sampling methods, see two previous AJN articles: “Newly Licensed RNs’ Characteristics, Work Attitudes, and Intentions to Work” (September 2007) and “New Nurses: Has the Recession Increased Their Commitment to Their Jobs?” (March 2012).7, 15
Data collection. Approval for the survey was obtained from the institutional review board at each author's institution. We collected data on the 2010–11 cohort using a mailed survey with a $5 incentive and a maximum of five mailings for nonresponders, using the same method we used to collect data on the 2004–05 cohort.15
Measures. We surveyed the two cohorts in four areas—personal characteristics, work attributes, perceived work environment, and job opportunities—using a total of 22 scales. Each scale had well-supported reliability (with a Cronbach α coefficient of more than 0.70) and validity in similar populations; they are described in detail elsewhere.15, 23 In addition, for the 2010–11 cohort we included new survey questions on patient safety (based on questions from the Agency for Healthcare Research and Quality; go to http://1.usa.gov/1aRHSQm) and on the ability of new nurses to obtain employment—two important, growing areas of research.
Data analyses. Response rates were 58% for the 2004–05 cohort and 47% for the 2010–11 cohort, according to the American Association for Public Opinion Research definition.24 Response rates varied by geographic area for the 2004–05 sample; therefore, we weighted responses for the 2010–11 sample so that any differences detected in the findings would not be caused by differences in response rate. All analyses were done with the weighted sample. We included 774 responders for the 2004–05 cohort and 1,613 responders for the 2010–11 cohort. We used PASW Statistics 20 to conduct t tests and χ2 analyses, with a significance level of 0.05.
Personal characteristics. As shown in Table 1, we found no significant differences between the two groups in age, sex, race and ethnicity, children at home, children younger than six years old, and basic nursing education. The 2010–11 cohort was significantly less likely to be married and to speak English as a first language and significantly more likely to be enrolled in a formal education program than the 2004–05 cohort.
Work attributes. There were significant differences between the two groups for most work attributes (see Table 2). Those in the 2010–11 cohort were less likely than those in the earlier cohort to be employed in a job requiring an RN license and less likely to work in a hospital; those who did work in a hospital were more likely to report they worked in a Magnet hospital and more likely to hold more than one job for pay. The later cohort was less likely to work in ICUs than the earlier cohort (11.6% versus 18%) and less likely to work in direct care (87% versus 93.1%). Although there were no significant differences in the type of shift worked, the later cohort was less likely than the earlier cohort to work full time and less likely to be part of a union. The later cohort was also less likely than the earlier cohort to report having the benefits of health insurance (91.9% versus 97.2%) or tuition reimbursement (69.4% versus 86.4%). The later cohort worked fewer hours of voluntary overtime and had a higher yearly income (although this was determined to be lower after the income of the earlier cohort was adjusted for inflation).
Work attitudes. NLRNs in the 2010–11 cohort viewed their work environment more positively than NLRNs from 2004–05 (see Table 3). In most cases, these differences were significant, although very small. Those in the later cohort perceived better nurse–physician relations than those in the earlier cohort, reported fewer organizational constraints, and were more committed to their organizations.
Job opportunities. The later cohort perceived significantly fewer job opportunities than the earlier cohort, both locally and not locally; 96.7% reported having zero to two employers. A significant percentage reported having a schedule they preferred (72.7%) and a shift they preferred (76.3%). Also, 68% of the later cohort applied for an RN job before taking the National Council Licensure Examination (NCLEX), 46.1% got their first RN job before taking the NCLEX, and 15.2% worked on a temporary or provisional permit before taking the NCLEX. While it took 10.2% of the later cohort four or more months to get an RN job, only 2.7% had no RN job offer by the time of the survey (a mean of nine months after passing the NCLEX).
Employment choices. When NLRNs in the 2010–11 cohort were asked to say why they took their first RN job, the most common reasons given (in descending order) were the work hours were good for work–life balance (44.3%), the commute was short (42%), the organization had a good reputation (39.9%), it was the only RN position that offered full-time employment (38.3%), the RN had clinical experience there as a student (34.4%), and a friend was at the organization (31%) (see Figure 1). NLRNs in the later cohort were much more likely than those in the earlier cohort to have left their first RN job within one year (16% versus 10.4%), although not all RNs had worked for a full year at the time of the survey. Of those who had already left their first job (n = 413) and answered the question about the one thing their employer could have done to keep them at that job (n = 199), by far the greatest percentage (42%) said there was nothing that could have kept them there. Other factors that might have kept them in their jobs (less than 10% each) were an increase in pay, a change in shift or hours, or improvements in management. About 25% worked on a shift or schedule that was not their preference. A large majority said they planned to enroll in additional formal nursing education (71.4%), many within five years (40.5%) or one year (35.5%); 20% were already enrolled.
Patient safety in 2012. The 2010–11 cohort perceived patient safety to be problematic in their work environments (see Figure 2). When asked whether they agreed with the statement: “Patient safety is never sacrificed to get more work done,” just over a quarter disagreed. Similarly, fewer than 20% disagreed with the statement: “Procedures and systems are good at preventing errors,” or agreed with the statement: “Have patient safety problems on the unit.”
The two cohorts reveal differences that could have implications for workforce planning. Some of these differences, such as job opportunities, may be related to the recent economic downturn and may diminish as the overall job market improves. Unlike Auerbach and colleagues, we found no significant differences in age between the two NLRN cohorts—but this could reflect the different sample sources.2 However, other differences likely result from evolving expectations and demands of the profession as health care environments change. For example, although the average ages of the two cohorts are the same, the later cohort's much higher enrollment in formal education may be influenced by the 2010 IOM report recommendation that 80% of the nursing workforce hold a BSN by 2020.14 Similarly, a population eager for primary care as a result of the ACA25 may motivate nurses with a baccalaureate to become NPs.
Our later cohort was much less likely to work in hospitals than the earlier cohort. Whether this resulted from the later cohort being less able to obtain a hospital job or preferring to work in other settings is not clear, but we believe the former to be true because of anecdotal reports of nurses’ having difficulty finding jobs. There are also anecdotal reports that hospitals are preferentially hiring RNs with a BSN and that if they do hire associate's degree graduates, they are requiring those nurses to get a BSN within a specified period. According to our unpublished calculations, BSN graduates are significantly more likely to work in hospitals within six to 18 months of graduation than associate's degree graduates (82.9% versus 67.1%), and associate's degree graduates in the 2010–11 cohort were much less likely to work in hospitals than those in the 2004–05 cohort (67.1% versus 83.1%).
The NLRNs in the 2010–11 cohort were also much less likely to work in special-care units, in part because they were less likely to work in hospitals. We suspect that hospitals can be more selective in hiring and prefer to hire experienced RNs in special-care units. Because hospitals can be more selective, we suspect that even if the new nurses were able to get hospital jobs, they were likely unable to obtain jobs in these specialty units.
Historically, most NLRNs provided direct care in hospitals and elsewhere.15 Our results indicate that this may be changing. The NLRNs in the 2010–11 cohort were significantly less likely to work in direct care than those in the 2004–05 cohort, and they were more likely to work as managers. The increase in second-degree RNs in the 2010–11 cohort may reflect that members of this group held management positions in another field prior to becoming RNs. The later cohort reported fewer local job opportunities, coupled with higher commitment to the organization that employs them. Thus, employers may be more likely to retain these NLRNs than those in the previous cohort, although there were no differences in the two groups’ intent to stay in their jobs. The later cohort was more likely to have been in a second job than the earlier cohort.
We were disappointed to find that significantly fewer 2010–11 licensees had the employer-provided benefits of health insurance and tuition reimbursement. This likely reflects the types of both jobs and employers (for instance, hospitals tend to offer more benefits than nursing homes), but it might also reflect that the later cohort was more likely to work part time and in jobs that often provide fewer benefits.
It is encouraging that NLRNs in the later cohort perceived their work environments more positively than those in the earlier cohort, especially in terms of better relations between nurses and physicians. This finding may be related to fewer RNs in the later cohort working in hospitals, where nurses tend to have the most interactions with physicians. It may also reflect the overall more positive perceptions of the RNs or that their positive perceptions improve nurse–physician relationships,15 continuing a trend of improvement that occurred from 2006 to 2009.7
The 2010–11 cohort reported continuing problems with patient safety. More than 26% disagreed or strongly disagreed that patient safety is never sacrificed to get more done and 19% reported having patient safety problems on the units in which they work. Further, 9% weren't comfortable reporting potential or actual safety problems. These patient safety problems persist even with the substantial investment that government and the health care industry have made in quality improvement.26, 27 It remains the work of nursing education programs and employers to eliminate these problems.28
Limitations. The sample was limited to NLRNs from 14 states, and although we have no reason to believe that changes within these geographic areas are systematically different from changes nationwide, our findings cannot be generalized to all NLRNs. Although the response rates were moderate for each cohort, there is the possibility that nonresponders had different experiences than responders. And with surveys there is always the potential for self-response bias.
Employers cannot presume that all NLRNs are similar. It is important for employers to continue to assess working conditions and how these conditions affect work attitudes and behaviors. Because of the interest the latest cohort has in ongoing education, employers may find it easier to hire BSN graduates than they have in the past. Employers should consider offering a tuition reimbursement as a benefit.
On a broader scale, these changing trends between RN cohorts are of particular interest to employers and policymakers. Our finding that the later cohort of NLRNs is less likely to work in hospitals is aligned with the demand to expand primary care services as outlined by the ACA. Fewer RNs working in hospitals leaves RNs available to work in primary care. Our data do not indicate that more NLRNs are working in community or primary care settings. But movement away from hospitals as NLRNs’ first place of employment is an important indicator of shifts in the nursing workforce that might have broader implications for U.S. health policy.
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For 65 additional continuing nursing education activities on professional issues, go to www.nursingcenter.com/ce.
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