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Today’s registered nurse practices in
a far more complex environment than in
the past brought about by continuing changes
in delivery of health care; rapid advances
in technology, drug therapy, and equipment;
increasing number of older adults with
multiple chronic conditions, and expanding
diversity of the country’s residents.
The development of myriad community-based
settings as sites for delivery of health
care requires a more autonomous practicing
nurse with higher levels of professional
knowledge and judgment and an expanded
set of skills. This changing environment
for nursing practice raises a multiplicity
of workforce, education and conditions
of practice issues.
Workforce
Slower growth rate of RN workforce.
The National Sample Survey of Registered
Nurses (NSSRN), a periodic study carried
out by the Division of Nursing, BHPr,
HRSA estimates that there were 2,696,540
RNs with current licenses to practice
in March 2000, an increase of 5.4 percent
over the 2,558,874 in March 1996. Although
these data demonstrate continuing growth
in the number of RNs the increase shown
in this four-year period is less than
that shown in all of the prior studies,
and markedly less than the 14.2 percent
increase experienced between 1992 and
1996.
RN workforce becoming older.
The “aging of the nursing profession”
and its impact on the availability of
nurses is the subject of numerous recent
journal articles. RNs are older today,
on average, than they have ever been.
The increasing age level of the RN population
is well documented in the NSSRN March
2000 study. The average age of the nurses
was 45.2 years compared to an average
age of 44.3 years in 1996. Sixty-eight
percent of the nurses in 2000 were at
least 40 years old. Only 9 percent were
less than 30 years old. More RNs are approaching
retirement age with fewer RNs to replace
them.
A very substantial percentage, 81.7
percent, or 2,201,813 out of 2,696,540
in the RN population in 2000, was actively
engaged in the variety of nursing positions
throughout the health care arena. Yet,
the percent working in 2000 was slightly
less than that found in the studies made
in the 1990s. For the first time the rate
of increase of the United States population
has surpassed that of the RN workforce.
In 2000, the ratio of RNs to 100,000 people
in the United States was 782 compared
to a ratio of 798 in 1996. There were
only an additional 86,000 nurses in the
active workforce of 2000 over that of
1996. The RNs who were not among these
actively employed nurses were mainly an
older group. Thirty-six percent were at
least 60 years old and an additional 23
percent were between the ages of 50 years
and 59 years.
Fewer entrants into the nursing profession.
The slower rate of growth and the continuing
aging of the nurse workforce are accompanied
by significant decreases in the numbers
of entrants into and graduates from nursing
education programs that prepare individuals
to become registered nurses. Data from
the National League for Nursing’s annual
surveys highlight the continuous decline
in the enrollments of all entry-level
nursing education programs since the 1993-1994
academic year. In October 15, 1993, there
were 270,228 students enrolled. By October
15, 1998, the start of the 1998-1999 academic
year, enrollments had fallen to 211,514,
a decrease of 22 percent.
Grave implications for nursing resources
of the future. Barring significant changes
in the flow of entrants into nursing,
research suggests that the supply of RNs
will start to decline within the next
10 years or so. In an article in the June
14, 2000 issue of the Journal of the American
Medical Association reporting on a study
analyzing the implications of the aging
nurse workforce for the future, the authors
project that the size of the RN workforce
will begin to decline in 2012. The authors
state that, by 2020, the RN workforce
will be 20 percent below projected requirements.
The Congressional Research Service (CRS)
in a May 18, 2001 report that reviewed
various studies of the supply and demand
for nurses states that evidence exists
of the supply in the RN labor market failing
to meet demand around 2010. Using data
from the Bureau of Labor Statistics (BLS),
the report indicates an increase of 450,864
new jobs for RNs between 1998 and 2008.
It also sees a need for substantial numbers
of RNs to replace those who would be retiring.
The report points out that, while all
industries will be faced with the need
to replace workers because of the aging
of the population, employers of RNs will
be particularly affected because of the
above-average proportion of nurses aged
45 years and older compared to other workers.
The NSSRN estimates that 46 percent of
the actively employed RNs in March 2000
were at least 45 years old. Only about
37 percent of a comparable part of the
civilian labor force in the country was
at least 45 years old in the year 2000.
CRS in its report states that BLS projects
that 42 percent of the total 794,000 RN
job openings through 2008 could be for
replacing retirees.
Increased diversity of the nation. In
March 2000, only 12 percent of the RNs
were estimated to be from minority backgrounds
compared to an estimated 30 percent of
the United States population. Research
has shown that there are substantial racial
and ethnic disparities in health. Although
a number of factors might account for
these differences, inadequate access to
quality and appropriate care is of paramount
importance. Nurses from minority backgrounds
are significant contributors to the provision
of health care services, and leaders in
the development of models of care that
address the unique needs of racial/ethnic
minority members of the country’s population.
Strategies directed toward attracting
and retaining increasing numbers of racial/ethnic
minorities into nursing are a prime consideration
in the reduction of health care disparities.
A competitive edge. Nursing remains
as an overwhelmingly female occupation.
Despite recent gains in the number of
men in the nurse workforce, 94 percent
of the actively employed RNs in March
2000 were women. These data are troubling
in the face of continually expanding opportunities
for women in other occupations. An article
in the September-October 2000 issue of
Nursing Economics$ documents the increased
interest among women in careers traditionally
dominated by men. It cites as examples
careers such as medicine and law that
are now likely to be equally listed by
men and women college freshmen. Thus,
to increase, or at least maintain, interest
in careers in nursing, particularly among
new high school graduates, recruitment
strategies to attract men as well as women
are critical.
Promoting nursing as an economically
attractive career is necessary for increasing
its competitive standing as a career choice.
Data from the periodic NSSRNs demonstrate
the gains made in nursing salaries in
the early 1990s. In more recent years,
however, nurses’ salaries show far less
gain. The average salary of full-time
employed RNs in 2000 was $46,782, an increase
of 24 percent since 1992. But when changes
in the purchasing power are taken into
account, RNs made essentially no gains
between 1992 and 2000. Full-time workers
in the professions of medicine, pharmacy,
law, and engineering, which might be competitive
career choices to nursing, averaged far
more than RNs in 2000. BLS estimated that
the median weekly earnings for RNs were
$790 compared to $1,340 for physicians,
$1,243 for pharmacists, $1,304 for lawyers,
and $1,104 for engineers.
Education
Increased complexity of care demands
a better educated RN. The nurse workforce
of today must be prepared for the increased
expectations arising out of the evolving
changes in the health care environment.
For currently practicing RNs, advanced
and continuing education are essential
to ensure their contributions to the efficacy
and safety of the patient care being delivered.
The nurse role of the present and future
calls for RNs to practice within a complex
healthcare system, to work as peers in
interdisciplinary teams and to integrate
evidence-based clinical knowledge with
knowledge of the diverse community and
its resources. The ever increasing complexity
of the RN’s scope of practice requires
a workforce that has the capacity to adapt
to change. It requires critical thinking,
problem solving and effective communicative
skills. A broad perspective and understanding
of health and factors affecting health
are needed to fill the RN roles in the
present reconstituted health care system.
All levels of RNs have an important role
to play in the evolving health care system.
Baccalaureate education with its broader,
more scientific base provides the sound
foundation for the variety of nursing
positions and for entry to advanced nursing
education and practice. Majority of today’s
RN population educated at less than the
baccalaureate level. According to the
NSSRN, in March 2000, only 43.6 percent
of the nurse workforce had at least a
baccalaureate degree. These data show
only a 2 percent change since 1996 when
41.5 percent of the nurse workforce had
at least a baccalaureate degree. In response
to the emerging health care system, NACNEP
set the following target in 1995:
- Increase the overall number of baccalaureate
and higher degree prepared nurses making
up the basic nurse workforce to achieve
2/3 BSN-prepared nursing workforce by
2010.
To meet this target, dramatic efforts
are needed for the 23 percent increase
between 2000 and 2010 in the percentage
of the nurse workforce with at least a
baccalaureate degree.
Only 10 percent of today’s nurse workforce
with graduate degrees. Graduate education
at the master’s and doctoral levels provides
the advanced knowledge necessary for specialized
nursing and health care; managing and
directing nursing in the varied complex
clinical care settings, and educating
the next generation of nursing students.
It is from the nurse workforce with graduate
education that those providing primary
care as nurse practitioners and nurse
midwives, and the nurse anesthetists are
primarily drawn. These practitioners make
substantial contributions to the care
of the underserved and those in rural
areas:
- Comparisons between certified nurse
practitioners and primary care physicians
show that 14 percent of nurse practitioners
provide primary care in high poverty
areas compared to 9 percent of physicians.
- Approximately 90 percent of certified
nurse-midwives provide care to low-income
women and 80 percent provide care to
uninsured women.
- Certified RN anesthetists administer
approximately 65 percent of over 26
million anesthetics administered each
year. They are the sole providers of
anesthetics in more than 70 percent
of rural area hospitals. RNs with graduate
degrees also function as clinical nurse
specialists to provide expert care and
advice in the particular specialty area
of their education. Moreover, graduate
degree RNs are the nurses providing
the managerial and administrative leadership
that supports effective quality nursing
care; the research that enhances and
promotes innovation in the nursing practice
and the delivery of health care, and
the faculty for the nursing educational
system.
Lack of availability of RNs for qualified
faculty. Nursing education programs at
all levels, from practical nursing education
to doctoral nursing education, employed
46,655 RNs in March 2000. Preparation
at least at the master’s degree level
is the generally accepted appropriate
qualification for teaching. For baccalaureate
and graduate education, the generally
accepted academic norm is the doctoral
degree. Data from the NSSRN indicated
that not all nursing educators meet these
criteria. In March 2000, 19 percent of
all the nurse educators had doctoral degrees
and 45 percent had as their highest level
of education, a master’s degree. The American
Association of Colleges of Nursing (AACN)
in an April 1999 Issue Bulletin discussing
faculty shortages outlines several issues
regarding the availability of faculty
among which was the inadequate numbers
of doctorally-prepared faculty. AACN indicates
that only slightly more than 50 percent
of the nursing faculty in its member universities
and senior colleges are doctorally-prepared.
The paper also cites as issues the declines
in master’s degree nursing students pursuing
academic careers and the aging of the
nurse faculty. Nurse educators tended
to come from the older segments of the
RN workforce, according to the March 2000
NSSRN. The average age of all the RNs
working in nursing education programs
was 49.4 years. Of significance throughout
is the competition between the nursing
education programs and the clinical and
administrative areas of health services
organizations for the relatively scarce
numbers of RNs with advanced degrees.
Need to broaden sites for clinical
experiences. Beyond the need to ensure
that sufficient qualified faculty is available
is that of the need to broaden the sites
in which clinical experiences for nursing
students are obtained. Clinical sites
for education need to reflect the realities
of community-based health services delivery
prominent in our restructured health care
environment. Hospital- focused clinical
education does not provide the breadth
and range of understanding of the practice
milieu necessary for today’s practitioner.
It is critically important to expand the
range of clinical sites for student experiences
to encompass more community-based health
care settings in both initial and advanced
educational programs. The growth of nurse-
managed centers under the aegis of nursing
education programs has proved valuable
in this connection. Not only do they serve
as a vehicle through which the underserved
can obtain health care but also they provide
students with access to working with patients
in the community. It is critical that
sources for stable and continuous financing
be provided to these clinics to ensure
their viability.
Continuing education required to update
RN knowledge. Rapid changes in health
care needs and treatment of health problems
make continuing education essential if
the quality of care is to be maintained.
To a large extent, today’s nurses were
educated in an era prior to the current
revolution in health care. Fifty-seven
percent of the RNs in March 2000 graduated
from the educational program that prepared
them to become nurses before 1985. Thus,
the need to “keep up” with the technological
advances of vastly expanding treatment
modalities is coupled with the need for
retraining and upgrading of skills to
function in this current, continually
changing, health care environment. The
responsibility for providing the opportunities
for RNs to maintain and enhance their
professional knowledge and skills is a
shared one. In addition to the responsibility
of employers to provide inservice education
that improves and maintains clinical skills
there is a need for continuing education
for practicing nurses in such areas as
geriatrics, genetics/genomics, informatics,
and other technological and specialty
fields.
Practice Improvement
Changes in health care system affect
distribution of nursing positions. Over
the past years the hospital was the central
focus of nursing education and much of
the practice of nursing. The hospital
setting still dominates as an employment
site for RNs but marked changes are occurring:
- Less than 10 years ago in March 1992,
66.5 percent of the 1.8 million employed
RNs worked in hospitals. Only 59 percent
of the 2.2 million employed RNs in March
2000 worked there.
- The movement of care from the inpatient
arena to an ambulatory base provides
for a shifting locus for RN employment
within the hospital. In 1992, 64 percent
of the RNs providing direct patient
care in hospitals worked in in-patient
bed units. In 2000, the percentage decreased
to 58 percent, as estimated from known
responses to the NSSRN.
- Between 1992 and 2000, the number
of RNs employed in public and community
health settings including such settings
as State and local health agencies,
home health agencies, community-based
clinics, student health and occupational
health services increased 61 percent.
The number employed in ambulatory care
settings, including physician, nurse,
and group practices and health maintenance
organizations increased 45 percent.
- Although far less than the gains
shown for the public/community health
and the ambulatory care sectors, the
number of RNs employed in nursing homes
also increased at a higher rate than
the number in hospitals, 18.5 percent
compared to 5 percent. Current difficulties
with filling RN positions. Increasingly,
media from all parts of the country
carry stories about difficulties in
recruiting RNs for vacant nursing positions.
In addition to reports of individual
institutions and agencies’ inability
to recruit RNs to fill staff vacancies,
data from a number of national and State
studies reveal significant shortages.
Most of the reported data focus on the
difficulties hospitals have in recruiting
sufficient numbers of nurses to fill their
positions. A stud y carried out by the
American Hospital Association in 2001
of 715 hospitals across the country revealed
that 126,000 of the 168,000 positions
in six job categories that were unfilled
were for RNs. Seventy- five percent of
the hospitals reported more difficulty
in recruiting for RNs in 2001 than the
previous year.
These data are reinforced by studies
made in various States. According to an
article in the South Florida Sun-Sentinel,
the Florida Hospital Association reported
that a vacancy rate for RNs of 11 percent
in 2000 increased to 15.6 percent in 2001.
The Association for Hospitals and Health
Systems in Maryland reported that the
percentage of unfilled RN positions increased
from 11 percent in 1999 to 13.9 percent
in 2000. A study made in Oregon showed
that vacancies for nurses in hospitals
ranged between 10 percent and 18 percent
and that high vacancy rates were also
being reported for other RN employment
settings.
RN dissatisfaction with employment
conditions. Along with the media reports
of vacant hospital nursing positions are
the reports of nurse dissatisfactions
with staffing levels that are insufficient
for providing appropriate care to patients
and mandatory overtime requirements that
exacerbate the unsafe practice conditions.
The General Accounting Office (GAO) in
its May 17, 2001 report on recruitment
and retention of nurses and nurses aides
indicates that job dissatisfaction may
affect the extent of the nursing shortage.
GAO states that recent surveys “have found
decreased job satisfaction, and a high
portion of respondents have reported increased
pressure to accomplish work, increased
required overtime, and stress-related
illness.” Based on estimates in the NSSRN
for March 2000, 73 percent of the RNs
in the active workforce were satisfied
with their jobs. But, a lower percentage
of those who were staff nurses in hospitals,
68 percent, were satisfied. The tension
caused by responsibilities for sicker
patients with complex conditions, and
the work schedules required by the need
to cover the 24- hour, seven day a week
care for patients, possibly contribute
to less satisfaction among hospital-employed
RNs. Also, these same conditions could
account for hospital-employed RNs retreating
to less stressful and demanding nursing
positions as variability in the types
of employment sites expands.
An aging nurse workforce has implications
for the work structure . The increasing
age level of RNs points to the need to
restructure nursing positions to accommodate
to the physical needs of older individuals
and the possible expectations that older
workers might have for independence and
more professional level interactions.
The age level of the available RN workforce,
in particular, affects hospitals. They
are more likely than other types of nurse
employment settings to draw their RN employees
from the younger age cohorts, those that
are predicted to be a decreasing part
of the RN workforce. Data from the NSSRN
for March 2000 show that the average age
of the RNs working in hospitals was 41.8
years, far lower than that for RNs in
ambulatory care settings, 44.3 years;
public/community health settings, 45.2
years; and nursing homes, 45.3 years.
Furthermore, RNs in the most stressful
and labor- intensive units in the hospital
tended to be younger than those in other
types of units. For example, the average
age of the nurses working in intensive
care units was 38.7 years; those in step-down
or transitional bed units averaged 38.8
years, and those in other types of bed
units averaged 41.1 years. Nurses working
in emergency departments had an average
age of 40.4 years and those in outpatient
departments, 44.5 years. Under current
circumstances, it is anticipated that
the aging of the nurse workforce will
continue in the future, thus materially
affecting the ability to recruit and retain
nurses in these stressful positions. Thought
has to be given to approaches to accommodate
to this phenomenon in order to attract
nurses to these positions and, once there,
to retain them.
The ability of the present nursing workforce
and the nursing education system to meet
the health care challenges of today and
the future is questionable. Currently,
the quantity of nurses is lacking and
projected to fall even further behind
the societal needs engendered by the demographic
aging curve of the population. NACNEP
believes that the many issues outlined
here about the size and the composition
of the workforce; the nurse educational
system and the work environment identify
matters for consideration in affecting
the current and future critical nursing
shortages. These must be addressed to
ensure the availability of the size and
quality of the RN workforce necessary
for the country’s health care service
requirements.
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