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Future Trends in Nursing Employment: The nursing shortage has made choosing the right career path easier.

Stevenson, Eleanor Lowndes MS, RN

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AJN, American Journal of Nursing: 2003 - Volume 103 - Issue - p 19-25

Registered nurses constitute the largest group of health care providers in the United States. As technology continues to advance and the status of hospitalized patients becomes increasingly complex, nurses are challenged to adapt to a changing environment. With this challenge come opportunities to find employment that is professionally enriching and personally satisfying. The current nursing shortage gives nurses the advantage of a broad selection of career choices. This article explores the shortage and its implications to practice, reviews potential solutions to it, discusses projections for future nursing employment, and suggests employment opportunities in specialty areas.


In a 2000 study, the Bureau of Health Professions, Division of Nursing, examined several aspects of the nursing profession including the estimated number of RNs, their educational backgrounds and specialty areas, employment settings, position levels, and salaries, geographic distribution, and personal characteristics. Study results showed that, as of March 2000, 2,696,540 registered nurses were licensed in the United States; an increase of only 5.4% from 2,558,874 RNs in 1996, the smallest observed since the survey began investigating nursing trends in 1977. Of these, 53.3% were employed as nurses full time, 28.4% worked part time, and 18.3% did not work in nursing at all. Of the 2.2 million nurses employed in the U.S., the majority, 59.1%, worked in hospitals. 1 (See Employment Settings of Registered Nurses, 2000, page 21 for a breakdown of employment settings.)

New England (Connecticut, Maine, New Hampshire, Rhode Island, Massachusetts, and Vermont) had the highest concentration of employed nurses relative to population, with 1,075 nurses per 100,000 people. The West South Central area (Arkansas, Louisiana, Oklahoma, and Texas) had one of the lowest, with 650 nurses per 100,000 people. However, the concentration in the Pacific area (Alaska, California, Hawaii, Oregon, and Washington) was even lower, with 596 nurses per 100,000 people. 1

The average age of nurses in 2000 was 45.2 years. About 32% were younger than 40 years of age, compared with 52.9% in 1980. Most significantly, the percentage of RNs younger than 35 years old dropped from 40.5% in 1980 to only 18.3% in 2000. And between 1980 and 2000, the nursing population younger than 30 dropped from 35.1% to only 9.1%. 1 (See Age Trends Among Nurses Under Age 40, above.)

In 2000, Buerhaus, Staiger, and Auerbach examined extensively the rise in age among registered nurses in the United States. They found that between 1990 and 2000 the average age of nurses increased by about three years and projected that it would increase three years by 2010, peaking at 45.4 years of age. This rise in average age will affect the future supply of nurses, as a greater proportion of them will retire than in times past. The investigators projected that the overall number of full-time RNs per capita will peak in 2007 and decrease through 2020. The actual number of employed nurses will begin to decrease in 2012 and by 2020 will approximately equal the number today, which is almost 20% below the projected need. 2


The nursing shortage is a vital topic, attended by dire predictions as well as suggestions of possible solutions to it. Projections of the number of nurses working in the U.S. in the next two decades are ominous. CNN reports that, according to a national survey prepared by the Federation of Nurses and Health Professionals, one in five plans to leave the profession in the next five years, and unsatisfactory working conditions were cited as the primary reason. 3

The increase in employment opportunities for women outside of nursing has adversely affected the profession, in which 94% are women. Additionally, despite their belief that their work is valuable and that they make a significant difference in peoples’ lives, nurses report frustration and disillusionment with their careers. 4 In a staffing survey of 7,299 nurses conducted by the American Nurses Association from December 2000 through January 2001, 75% indicated a decline in the quality of care provided by nurses at their work facilities over the preceding two years. Fifty-six percent said they had less time to spend with their patients. More than half of the respondents said that they would not recommend the nursing profession to their children or friends. 5

A federal study conducted by the U.S. General Accounting Office and presented to the House of Representatives Subcommittee on Health in 2001 identified two principal factors that affect the recruitment and retention of nurses: 1) an aging workforce, in which fewer younger people (less than 30 years old) are entering the profession, and 2) job dissatisfaction—a result of undesirable working conditions that include inadequate staffing, heavy workloads, increased imposition of mandatory overtime, lack of adequate support staff, and inadequate wages. 6

The nursing shortage is not exclusive to the United States. According to Sigma Theta Tau International, nursing’s honor society, Canada, the Philippines, Australia, and Western Europe also are experiencing significant shortages. Africa and South America are experiencing nursing shortages as well. As a result of this, experienced nurses are in great demand, especially those with diverse clinical backgrounds in specialties such as OR/recovery, ED, ICU, critical care, pediatrics, neonatal intensive care, pediatric intensive care, and labor and delivery. 7 A report issued by the New York State Nurses Association also cites a shortage of nurses in critical care, OR, and ED. 8


Several initiatives have been undertaken to improve the current shortage, as well as to anticipate a future one. In response to the fact that mandatory overtime is becoming increasingly common in hospitals and is cited as a significant cause of job dissatisfaction, the ANA has made prohibition of it a legislative priority at both the state and federal levels. 9 Additionally, it has identified other high priorities, which include: 1) the provision of additional workplace protection to enable nurses to report unsafe conditions without fear of reprisal; 2) the mandatory collection of workforce and nursing-sensitive quality data that would render health care facilities publicly accountable for the quality of care provided; and 3) the establishment of a classification system to determine appropriate nursing staff level and mix. 5

Hospital administrators are seeking new ways of maintaining and, ideally, increasing staff members in the areas most adversely affected by the shortage. A number of creative programs have been designed to keep nurses employed at the bedside. In 1998, Children’s Hospital Los Angeles developed a program in an acute care pediatric setting for new nursing graduates—the RN Internship in Pediatrics. This program included extensive preceptorship, mentorship, varied clinical exposure, and additional time for practicing hands-on skills in training laboratories. After eight months, the interns demonstrated clinical competence equivalent to that of nurses with two years’ experience and a decreased turnover rate after six months (14% among interns, 36% among the control group). 10

Other approaches explore ways of encouraging people to consider nursing as a viable and exciting career choice. The University of Maryland School of Nursing has developed a Strategic Plan for 2002 for workforce development in an attempt to raise public awareness of the nursing shortage by increasing advocacy within the profession, supporting legislation that addresses the shortage, expanding access to education through technology (such as implementing distance learning classrooms), and offering creative and flexible curricula to meet the needs of older students. The school is also attempting to remove financial barriers for potential nursing students, to work with news media and employ marketing strategies to overcome outdated perceptions of nursing, to create a prenursing academy with the Baltimore public school system, and to foster a collaborative practice relationship among health professionals that will promote respect accorded to nurses as members of the health care team. 11 If successful, these efforts could constitute a model to be followed at other institutions.

The Pennsylvania Girl Scouts introduced an interesting initiative to spark interest in nursing at an early age—the Nursing Exploration patch. Junior, Cadet, and Senior Girl Scouts can earn the patch by completing activities such as studying the life and work of a famous nurse, learning about teenage drug abuse, earning CPR certification, and learning how a body system works, which can increase their awareness of opportunities in nursing. 12

The Southern Vermont Area Health Education Center has created the position of Health Careers Mentor, a nurse who introduces nursing as a career to middle and high school students. She engages speakers, counsels students in the selection of college preparatory classes, and helps them with the college and financial aid application processes for pursuing nursing education. Additionally, interested students are directed to volunteer work, job shadowing (observation of a nurse’s daily routine), and related classes held outside their schools. 13


Travel nursing emerged as a solution to the 1980s nursing shortage, particularly to fulfill the need for nurses in areas that experience seasonal population fluctuations (for example, Florida, Arizona, California, and Texas). The use of traveling nurses has doubled in the last five years, with an estimated 15,000 filling staffing needs on a temporary basis. The current nursing shortage is forcing hospitals to rely increasingly on travel nurses who, at an average of $60 to $75 per hour (depending on the benefits package), often earn twice as much as staff nurses do. These costs, while necessary to fill critical needs, significantly affect the overall financial status of many institutions. One survey revealed that the average hospital in California spends about $1 million to $1.5 million each year on registry and travel nurses, above the cost of employing full-time nurses alone. 14,15

Information on becoming a travel nurse is plentiful and easily accessible on the many Web sites maintained by placement agencies, one of which advertises enticing perks—the sunny skies of California in winter, the big-city excitement of New York and San Francisco, and the wintry mountain slopes of Colorado and Vermont. 14 The National Association of Traveling Nurses represents these nurses, disseminates information to vendors as well as nurses, and provides certification of nurses serving in this capacity. The association’s Web site offers members a multitude of resources, from job postings to free e-mail service. 16

Traveling nurses must be well-organized, flexible, and independent. Strong clinical competence in various specialty areas is advantageous. Assignments typically require three-to-six-months’ commitment. The benefits are usually good: Most agencies provide health benefits, 401(k) plans, and completion and referral bonuses. 17

Registered Nurse First Assistant (RNFA). Nurses with at least two years of perioperative experience, a BSN degree, and certification as an operating room nurse (CNOR) may complete a formal RNFA education program. Once credentialed, they can serve as first assistants in various types of surgeries, depending upon the institution. RNFA duties include handling tissue, helping to expose the surgical site, maintaining hemostasis, and suctioning and suturing under the direction of a surgeon, as well as providing pre- and postoperative patient care. Although RNFAs are allowed to practice in all 50 states and are supported by the American College of Surgeons, their specific duties are defined by both the state Nurse Practice Act and the institutions at which they are employed. Information on this dynamic career, which was initiated in 1983, can be obtained through the Web site of the Association of Operating Room Nurses, 18,19

Clinical research. Research involving human subjects is strictly regulated by participating institutions as well as by the federal government. Because nurses adapt easily to the complex structure of clinical research trials, they are often employed as clinical research coordinators (CRCs) and clinical research associates (CRAs). Neither job requires additional formal training.

CRCs function primarily at the study site and are employed by the institution conducting the research. They recruit subjects, conduct physical assessments, perform many of the study procedures, monitor potential adverse events, manage data, and often act as a liaison to the sponsors of the research. Although research trials are conducted in all parts of the country, large academic institutions are most likely to conduct them and CRC jobs therefore are usually found in large, urban environments.

CRAs, on the other hand, are responsible for monitoring clinical trials through intermittent visits to clinical sites and the conducting of the actual research. Their responsibilities include reviewing study documents for accuracy, helping to maintain patient safety, managing experimental drug supplies at the sites, and ensuring good clinical practice. Although CRA positions exist throughout the country, most opportunities are in the Northeast, where a large percentage of pharmaceutical and biotechnology companies are located. The CRA works in a corporate environment and is frequently required to travel. 20,21

Established in 1989, the Legal Nurse Consultant (LNC) specialty is growing rapidly. In this position, nurses with significant clinical expertise offer a variety of services to law professionals or as independent contractors as expert witnesses or interpreters of medical records, documents, and scientific literature. Insurance companies also seek their services as claims adjusters or case managers. To become a legal nurse consultant, candidates must have at least two years of relevant clinical experience and have completed a legal nurse consultancy program, offered by many colleges. Certification is offered through the American Legal Nurse Consultant Certification Board but is not required.

Legal nurse consulting is expected to have growth opportunities comparable to those that have been seen in the paralegal profession, which the U.S. Department of Labor cited as one of the five fastest growing professions in the country. LNC salaries are competitive: independent consultants charge from $60 to $150 per hour for their services. Visit the American Association of Legal Nurse Consultants Web site at for more information. 22

The nurse informaticist specialty evolved in response to the emergence of the information age. For nurses seeking the excitement of using the latest technology and taking their careers in a different direction, nursing informatics may be the right choice. Nurse informaticists use computer skills and their expertise in information science and nursing science to manage and disseminate data, information, and knowledge within the practice of nursing (for example, integrating patient data to facilitate efficient health care decisions). Such nurses are employed as consultants to vendors in the private sector (the companies developing the technologies), as systems designers and analysts in the clinical setting, and as faculty members and researchers in education. This specialty requires a bachelor’s degree, two years of clinical experience, and 2,000 hours in the field of informatics or 12 credits in a graduate program and 1,000 hours in informatics. These requirements may change to support graduate education, the only entry into this area. 23

Nurse educator. Parallel to the current and anticipated nursing shortages is the nursing faculty shortage. In order to have nurses at the bedside, they must first be educated. The average age of nursing faculty members is 50.2 years, and it’s estimated that in 2006 one-third of them will have retired.

Nursing is one of the few professions in which new graduates are not directed to pursue graduate education immediately but, rather, are encouraged to obtain clinical experience before considering a faculty position. The average age of a new doctoral recipient in nursing is 45 years, compared with 34 years in all other fields. For having pursued clinical experience before undertaking doctoral study, nurses do not hold faculty positions as long as educators in other disciplines do.

Now may be the time to continue your studies, as opportunities for advanced education abound and many institutions offer financial assistance, making it a feasible choice. Nurses can teach at universities and schools of nursing with a master’s degree, although doctoral preparation is more desirable. No matter how many efforts are made to attract young people to the field of nursing, without nurses to educate them, the workforce shortage is likely to worsen. Education can afford nurses the opportunity to give something back to the profession in a most rewarding fashion. 24–26


If you decide to leave the bedside, you don’t have to leave the profession. The opportunities described here constitute only a fraction of those available to resourceful nurses looking to further their careers while making a significant contribution. Nursing can provide a lifetime of rewarding professional experiences and personal satisfaction.


Age Trends in Nurses Under Age 40, 1980 vs. 2000 1
Employment Settings of Registered Nurses, 20001


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© 2003 Lippincott Williams & Wilkins, Inc.