1. More Nurses
are Needed, but More is Not Enough
1.1. Introduction:
Nursing Challenges in a Rapidly Changing,
Complex Health Care Environment
The organization and delivery of health
care in the United States is continually
changing in order to meet economic challenges
and adopt improvements and innovations
in patient care. At the same time financial
pressures are driving organizations to
reduce costs and increase efficiency,
the funders and consumers are demanding
greater focus on the quality of health
care and its impact on patients’ outcomes.
The health care system in the United States
is becoming ever more complex at a time
when a growing and aging population is
demanding increasing amounts of health
care services.
Nurses are the single largest component
of the health care workforce. They not
only provide the majority of direct care
to patients, but also are major partners
in health care management and policy.
The supply of Registered Nurses (RNs)
is not keeping up with demand and that
problem will worsen as more of this aging
workforce retires. According to projections
from the United States Bureau of Labor
Statistics, more than one million new
and replacement RNs will be needed by
2012 (United States Department of Labor,
Bureau of Labor Statistics, 2004). A
recent projection shows that by 2010,
the largest group of working RNs will
be in their 50s, and by 2020 there will
be a significant increase in RNs in their
60s. There are predictions that the shortage
of nurses will become a crisis long before
2020 (Buerhaus, 2005).
| There are three
different avenues for entry-level
RN education: associate degree programs,
diploma programs, and baccalaureate
degree programs. It takes approximately
two years to complete an associate
degree program, three years for a
diploma program, and four years for
a baccalaureate program. |
It is critical that the United States
produce greater numbers of nurses to meet
the growing demand. It is equally important
that the country build a nurse workforce
with the skills and abilities needed in
this increasingly challenging health care
environment.
Given the shortage of nurses in the United
States and the changing health care environment,
policymakers are faced with major challenges.
However, producing more nurses quickly
will not meet the overall needs of the
health care system. Both newly educated
nurses and those already in the workforce
need educational and practice opportunities
to better prepare them to meet the new
challenges in the health care environment.
The specific expanded or new capabilities
required for success include: the critical
thinking skills to rapidly acquire and
assimilate new information and to use
that information to make appropriate patient
care decisions; skills and knowledge required
for working with innovations in patient
care; and increased cultural competence
to interact appropriately with individuals
from a variety of backgrounds.
1.2. The Capabilities,
Skills, and Nursing Resources Required
in Modern Nursing Practice
The rapidly changing health care environment
requires nurses with strong critical thinking
and analytical skills as well as the ability
to provide professional and compassionate
care. These critical thinking and analytical
skills are required to acquire and assimilate
data in order to make appropriate patient
care decisions. Nurses need interdisciplinary
competencies supported by backgrounds
in the sciences as well as the humanities.
In order to ensure patient safety, provide
quality care, and deliver patient care
efficiently, nurses must be able to gather
and synthesize new information and address
needs as they emerge. This is critical
not only for health care delivery systems
– where the workforce must be able to
adapt to new developments and technologies
– but also for communities that need a
workforce prepared to provide emergency
response for natural and man-made disasters.
With the prospect of the nursing shortage
worsening, nurse-patient staffing ratios
become more important. There is a growing
body of research that associates inadequate
nurse staffing with adverse patient outcomes,
including mortality and other adverse
events. For example, studies by Aiken,
Clarke, Sloane, Sochalski, and Silber
(2002) found that each additional patient
per nurse results in a seven percent increase
in the likelihood of dying within 30 days
of hospital admission. Other studies
have found associations between low nurse
staffing levels and hospital-acquired
pneumonia, urinary tract infection, sepsis,
nosocomial infections, pressure ulcers,
upper gastrointestinal bleeding, shock
and cardiac arrest, medication errors,
falls, and longer than expected length
of stay (Needleman & Buerhaus, 2003).
Evidence shows that more nurses are associated
with better hospital outcomes (Needleman
& Buerhaus, 2003). Needleman, Buerhaus,
Mattke, Stewart, and Zelevinsky (2002)
found higher rates of hospital RN staffing
to be associated with a three to 12 percent
reduction in adverse outcomes. Aiken
and colleagues (2002) found RN job dissatisfaction
levels were more elevated in hospitals
with high patient-to-nurse ratios than
in hospitals with low patient-to-nurse
ratios.
Increased levels of nurse staffing means
improved nurse-to-patient ratios. This
leads to better patient safety (including
more opportunities for patient monitoring
and interaction) and reduces risks for
unsafe conditions, thereby yielding better
patient outcomes. Improved nurse-to-patient
ratios also means more opportunities for
patient monitoring and interaction, which
includes attending to patients’ psychosocial
needs. Having more nurses available at
a patient care site also improves the
availability of cross-coverage when one
patient’s care demands a greater proportion
of an individual nurse’s time.
Larger numbers of nurses, regardless
of their level of education, leads to
better patient outcomes. However recent
research suggests that increased proportions
of nurses with baccalaureate degrees are
associated with even better patient outcomes.
Aiken, Clarke, Cheung, Sloane, and Silber
(2003) found, among one state’s hospitals,
that every 10 percent increase in the
proportion of RNs holding baccalaureate
degrees was associated with a five percent
decrease in mortality and failure to rescue
following common surgical procedures.
The study did not examine how baccalaureate-educated
RNs contributed to better patient outcomes
but more nursing education is likely to
provide students with a broader and more
in-depth knowledge base. Associate and
baccalaureate students take the same licensing
exam to achieve certification. The baccalaureate
education program, as compared to the
associate degree program, includes more
liberal arts courses, and instruction
in community health, public health, research,
nursing leadership, and nursing management.
This additional background enables nurses
to anticipate and monitor for potential
complications, recognize the onset of
problems, and decrease the need for crisis
management. These skills may lead to
better patient outcomes. The skills and
knowledge needed to practice evidence-based
nursing are taught in most baccalaureate
programs.
1.3. Current
Trends in the RN Workforce
As the supply of RNs has grown, the demand
for RNs has grown more rapidly. Projections
show RN supply growth ending in the next
few years (largely because of expected
retirements among the large proportion
of baby boom generation nurses). The
gap between RN demand and supply is projected
to expand to potentially insurmountable
levels over the next decade and a half.
Even if nurses begin to retire at older
ages, without huge increases in the numbers
of new RNs, or tremendous reductions in
demand for their services, there will
be greater and greater shortages of RNs
in the United States (see figure 1) (Health
Resources and Services Administration,
2006).
[D]
Source: Health Resources and Services
Administration, 2004
Recent Trends
in the Workforce
Between 2000 and 2004, the number of
RNs in the United States grew by about
200,000 according to recent reports based
on the 2004 National Sample Survey of
Registered Nurses (NSSRN). As the number
of RNs has grown, they remain predominately
female: the proportion of male RNs has
grown from 5.4 to only 5.7 percent since
2000. The average age of RNs increased
by 6.5 years since 1980 to an average
of 46.8 years in 2004, and 73.4 percent
of all RNs were age 40 years or older.
Figure 2 shows the age shift of RNs since
1980 (Health Resources and Services Administration,
2004). This aging of the nurse population
is the major factor supporting projections
of a decline in the RN supply beginning
in the next two to seven years as the
baby boom generation reaches retirement
age.
[D]
Between 1977 and 1997, the number of
RNs from minority backgrounds grew from
6.3 percent to 9.7 percent of the total
population of RNs (Buerhaus & Auerbach,
1999). The 2004 NSSRN found 10.6 percent
of RNs identified as non-white. Comparisons
of racial/ethnic composition of the RN
population across time are complicated
because of changes in definitions of race/ethnicity
initiated with the 2000 United States
census. Regardless of the difficulty
of closely tracking changes over time,
the United States’ RN population in 2004
remained significantly less racially and
ethnically diverse than the overall population
of the United States: 88.4 percent of
RNs identified as white, non-Hispanic,
compared with 67.9 percent for the overall
United States population (Health Resources
and Services Administration, 2004).
In 2004, 33.7 percent of nurses (981,238
RNs) reported the associate degree as
their highest level of nursing or nursing-related
education, 34.2 percent (994,276 RNs)
reported the baccalaureate degree as their
highest level and 13.0 percent (376,901)
reported a master’s or doctoral degree
as their highest level (see Figure 3)
(Health Resources and Services Administration,
2004).
From 2000 to 2004, the percentage of
RNs whose highest nursing or nursing-related
educational preparation was a baccalaureate
degree increased from 32.7 percent to
34.2 percent (the number increased from
880,997 RNs in 2000 to 994,276 RNs in
2004). Overall, this is a 170 percent
increase in RNs with a baccalaureate degree
since 1980, when 367,816 RNs held baccalaureate
degrees (Health Resources and Services
Administration, 2004).
Figure 3
[D]
Source: Health Resources and Services
Administration, 2004
Approximately 3.5 percent of RNs in 2004
(nearly 101,000 RNs) were foreign-educated.
Nearly 60 percent of these nurses had
BS degrees or higher, and over two percent
(2,446 RNs) had advanced practice preparation.
The majority of foreign-educated RNs came
from the Philippines (50.2 percent), followed
by Canada (20.2 percent), and the United
Kingdom (8.4 percent) (Health Resources
and Services Administration, 2004).
The United States has one-fifth of all
the world’s nurses (Larson, 2006). Congress
allocated 50,000 additional visas for
foreign-born nurses in 2005; legislation
has been proposed by the hospital industry
for 200,000 more visas (Aiken, 2005).
As a result of capacity constraints, schools
of nursing in the United States are turning
away tens of thousands of qualified students
at the same time the country is increasing
its reliance on foreign-born nurses.
Recent Trends
in the Workplace
Between 2000 and 2004, fewer RNs left
nursing than between 1996 and 2000, reflecting
the lowest attrition rate since 1992 to
1996. However, new entrants to nursing
decreased slightly between 2000 and 2004,
far below the 1992 to 1996 numbers (Health
Resources and Services Administration,
2004).
The majority of RNs in the United States
in 2004, according to NSSRN findings,
worked in hospitals, but that number dropped
from 66.5 percent in the early 1990s to
57.4 percent in 2004. The proportion of
RNs working in ambulatory care settings
has continued to increase (from 7.8 percent
in 1992 to 11.7 percent in 2004), while
the proportion working in nursing homes
or extended care settings (6.5 percent
in 2004) changed only slightly in the
past decade. Compared with the overall
RN population, foreign-educated RNs are
more likely than their U.S.-educated counterparts
to work in hospitals (64.7 percent), and
nursing homes and extended care facilities
(11.1 percent) (Health Resources and Services
Administration, 2004).
The average annual earnings of RNs employed
full-time in 2004 were $57,784 which is
a 23.5 percent increase from average earnings
in 2000 ($46,782). From 2000 to 2004,
the Consumer Price Index (CPI) increase
was 9.5 percent. As such, the increase
in earnings, in real terms, for this period
was 14.0 percent (23.5 percent actual
increase, less the 9.5 percent CPI) (Health
Resources and Services Administration,
2004).
In 2004, the majority (78 percent) of
working RNs with current licenses to practice
in the United States were satisfied with
their principal nursing positions: 27
percent of RNs were “extremely satisfied”
and 50.5 percent were “moderately
satisfied” (Health Resources and
Services Administration, 2004). Buerhaus
et al. (2005) surveyed hospital-employed
RNs nationwide in 2002 and 2004, finding
results that were similar to those of
HRSA. Most hospital-employed RNs reported
satisfaction with their jobs in both the
2002 and 2004 surveys by Buerhaus et al.
Eighty-three percent of nurses said they
were “very” or “somewhat”
satisfied with their jobs in those surveys,
and the percentage indicating “very”
satisfied increased from 21 percent to
34 percent over the two years. The nurses
in those surveys also were highly satisfied
with their profession (87 percent in both
2002 and 2004), and more than 70 percent
said they would “definitely recommend”
the field of nursing to a qualified student.
Aiken and colleagues (2002) however found
significant dissatisfaction levels among
hospital nursing staff. For example, in
a survey of nurses in Pennsylvania, 41.5
percent were dissatisfied with their jobs.
In addition, 43.2 percent of these staff
nurses reported high levels of emotional
exhaustion. The potential stressors one
might more commonly associate with nursing
(coping with pain, disability, and death)
were not found to be the root cause of
burnout. Instead, causes of this burnout
were attributed to dysfunctional organizations
and the need to continually utilize workarounds.
The National Database of Nursing Quality
Indicators satisfaction survey, which
included 400 hospitals in 2005, found
hospital nurses to be highly satisfied
with regard to interactions with other
RNs, their professional status, and professional
development opportunities, but reported
very low satisfaction with decision-making,
tasks, and pay (Blakeney, 2005).
The leading recommendation for solving
the nursing shortage, as cited by RNs
responding to national surveys in 2002
and 2004, was to improve the work environment
(Buerhaus et al., 2005). The majority
of nurses responding to the later survey
indicated that the nursing shortage had
negative effects on patient care including
the timeliness, patient centeredness,
effectiveness, efficiency, and the safety
and equity of care. Some improvements
in the work environment reported by respondents
between the first and second surveys were
decreased mandatory overtime, less job
stress, more perceived job security, more
recognition by front-line management of
the importance of personal and family
life, and better relationships among nurses.
1.4. The RN
Workforce Challenge: Building Nursing
Supply and Skills to Meet Changing Patient
and System Demands
The demand for nurses is growing faster
than the supply; meanwhile, the required
skills and knowledge of the nursing workforce
are expanding to meet the challenges of
an increasingly complex health care environment.
The challenges for educators, policymakers,
health care systems, and the nursing workforce
are to build the RN supply to meet demand,
and promote development of the skills
required in this changing environment.
Building the
RN Supply
This section discusses factors affecting
the Nation’s supply of RNs. One of the
key factors is output from schools of
nursing. Producing more new nurses requires
an increase in both qualified students
applying to schools of nursing and capacity
for educating students in the schools.
A 2006 survey by the American Association
of Colleges of Nursing (AACN) found that
the number of graduates from entry-level
baccalaureate programs increased by 18
percent from 2005 to 2006. The recent
rise in graduations follows 3.2, 4.3,
14, and 13.4 percent increases in the
number of graduates in 2002, 2003, 2004,
and 2005, respectively (American Association
of Colleges of Nursing, 2006c). In April
2006, HRSA projected that nursing schools
must increase the number of graduates
by 90 percent in order to adequately address
the nursing shortage. With an 18 percent
increase in graduations from baccalaureate
nursing programs in 2006, educational
institutions fell far short of meeting
this target.
Recent public relations promotions, such
as the Johnson & Johnson Campaign
for Nursing’s Future and the national
media campaign by the coalition of Nurses
for a Healthier Tomorrow, are viewed as
successful efforts to promote a positive
image of nursing and increase the number
of applicants to nursing schools. The
Johnson & Johnson campaign in particular
aimed to show nursing as a well-paid profession
for men and women from diverse backgrounds.
The U.S. Bureau of Labor Statistics reported
that in 2002, nurses earned significantly
more than police officers, dieticians,
and teachers. Nurses, with an annual
median income of almost $50,000, earned
nearly $11,000 more than social workers
(LaRocco, 2006). These image-promotion
campaigns, combined with economic factors
such as increased nurse salaries and benefits,
have fueled a problem now common at many
schools: there are now more qualified
applicants than available nursing school
openings. Nursing programs and universities
have not been able to keep up with strong
student interest primarily because they
do not have enough qualified faculty members,
classroom space, and clinical training
resources. AACN’s findings show that
in 2006, 32,323 qualified applications
to entry-level baccalaureate programs
were not accepted. The number of qualified
applicants turned away each year from
these programs remains high with 3,600,
15,944, 29,425, and 37,514 applicants
turned away in 2002, 2003, 2004, and 2005,
respectively (American Association of
Colleges of Nursing, 2006c).
More education funding, from tuition
and from state and Federal sources, can
help alleviate this problem. Even with
more financial resources, however, it
still may not be possible to pay teaching
salaries that are high enough to lure
RNs with advanced degrees (which are among
the requirements for faculty positions)
away from higher paying clinical positions.
The 2005 American Association of University
Professors (AAUP) survey of faculty compensation
found the average salary in 2004–05 for
full professors at baccalaureate institutions
was $74,408; for associate professors,
it was $57,468; for assistant professors,
it was $47,834. In contrast, the median
2002–03 salaries for nonacademic positions
such as vice president for nursing was
$113,100; for nurse anesthetist, it was
$105,890; for nursing director, it was
$93,344; for nurse practitioners, it was
$69,407. The 2005 salary range for full-time
clinical nurses at one Boston hospital
was $54,000 to $116,000 (American Association
of University Professors, 2006).
Finding clinical training sites and appropriate
supervision for growing numbers of nursing
students is becoming more and more difficult.
Supervising students’ clinical training
is time and labor intensive for RNs in
clinical settings. Beginning in their
sophomore year, nursing students typically
spend six to 12 hours per week in a hospital
or other practice setting under the direction
of a faculty member. The ratio of students
to faculty is generally eight to one.
Specialty practices, such as pediatrics,
may allow a nursing instructor to supervise
as few as six students. Part-time clinical
faculty members provide most of this labor-intensive
supervision. Although individual state
boards of nursing regulate nursing education,
clinical instructors must have a master’s
degree in nursing in most states. In
2002, however, because of the shortage
of qualified faculty, Massachusetts began
to allow schools to obtain a waiver of
this regulation, allowing clinical-setting
teaching by nurses holding bachelor’s
degrees with at least five years of full-time
experience, those with master’s degrees
in fields other than nursing, and nurses
enrolled in master’s degree programs in
nursing. Qualified (that is, master’s
prepared) faculty must supervise these
instructors who have a waiver, which adds
to the faculty members’ workload (LaRocco,
2006).
Average retirement age of RNs is the
primary factor affecting the supply of
RNs in the United States. Because of
the large proportion of RNs (73 percent)
who are age 40 or older, their retirement
will have a large impact on the workforce.
As shown in Figure 2, if the average age
of retirement of RNs is delayed by a few
years, there can be a significant positive
impact on the supply of RNs (Health Resources
and Services Administration, 2004).
The number and proportion of RNs working
part-time is another factor. This number
increased between 2000 and 2004. In 2000,
23.2 percent of RNs (approximately 702,000
RNs) worked part-time, compared with 24.8
percent (approximately 724,500 RNs) who
worked part-time in 2004 (Health Resources
and Services Administration, 2004; Spratley,
Johnson, Sochalski, Fritz, & Spencer,
2000). The greater the proportion of
RNs who work part-time, as opposed to
full-time, the more that are needed to
meet nursing demand, putting additional
strain on the RN education system. A
dilemma for planners and policymakers
is whether to encourage any limits to
part-time employment when one successful
strategy for RN retention is to accommodate
nurses who desire to work less than full-time.
The number of nursing workforce exits
and re-entrants also affects the total
supply of RNs in the United States. In
2004, approximately 17 percent of licensed
RNs were not actively working in nursing
(Health Resources and Services Administration,
2004). While some nurses regularly drop
out of clinical practice, some nurses
who had been part of the non-practicing
pool in previous years return to active
nursing each year. There is always flow
in and out of the workforce, but because
of the shortage and the education capacity
problem, there are clear advantages to
maximizing retention. Finding ways to
encourage RNs to remain in the workforce
as long as possible is critical to building
the RN supply to needed levels.
Another factor affecting the supply of
RNs is immigration of foreign-educated
nurses. RNs educated in many other countries
are attracted to the United States by
comparatively high nursing salaries.
As with many occupations, RNs from other
countries move to the United States to
work through employment visas or by immigrating.
During times of RN supply shortfalls,
the number of foreign-educated nurses
may rapidly increase when U.S. employers
actively recruit RNs from other countries
by sending recruitment teams abroad, providing
signing bonuses, paying travel expenses,
and/or providing housing in the United
States.
Solutions to meet the nursing supply
challenge must address the factors described
above. States, communities, and health
care institutions are committing resources
to these efforts to increase nursing supply.
Where possible, these resources should
be increased. But reaching the levels
of nursing supply needed to meet the country’s
growing demand will require even more
efficient use of these resources. The
preparation of the nursing workforce and
programs to recruit and retain nurses
should be based on empirical data that
identify the most effective and efficient
methods and take into account trends and
forecasts for future workforce needs.
Skills Required
in an Increasingly Complex Health Care
Environment
It will not be enough only to increase
the supply of RNs. What is needed is adequate
numbers of qualified, culturally diverse
nurses prepared to practice competently
in an increasingly complex health care
environment. To achieve this end, the
nursing curriculum needs to go beyond
teaching students traditional skills —
the curriculum must also provide a strong
focus on science, technology, and the
humanities to enhance the nurses’
abilities to work with complex physical,
social, and psychological problems in
the delivery of safe, efficient, and effective
care. In addition, curricula must provide
the ability to critically analyze information
in implementing evidence-based practice.
Also important is the ability to enable
patients to be key decision makers in
care processes that respect the patients’
preferences, values, and needs. Finally,
curricula must impart cultural sensitivity
and competence because those attributes
are related to patient outcomes.
The additional education time and the
focus of the curriculum in baccalaureate
nursing programs provide the most conducive
environment for producing RNs with these
attributes. As described in Section 1.2
of this report, there is a growing body
of evidence showing that having more baccalaureate-trained
nurses in some hospital settings is associated
with decreased mortality and adverse patient
events. Thus, while graduates from associate
degree and diploma programs are needed
to make an important contribution to the
workforce, the National Advisory Council
on Nurse Education and Practice strongly
recommends prioritizing funding for initiatives
to increase the proportion of BSNs in
the nursing workforce. This includes giving
funding preference to pre-baccalaureate
(associate degree/diploma) education programs
that demonstrate a plan to foster baccalaureate
preparation with partnerships between
baccalaureate and pre-baccalaureate programs.
The First Report of the National Advisory
Council on Nursing Education and Practice
(NACNEP) recommended the goal of realizing
a basic RN workforce with at least two-thirds
holding baccalaureate or higher degrees
by 2010 (National Advisory Council on
Nurse Education and Practice, 2001). Statistics
show the proportion increased from 43
percent in 2000 to only 48 percent in
2004 (Health Resources and Services Administration,
2004). At this rate of increase, the goal
of 67 percent will not be reached for
another decade without significant infusion
of resources and energy.
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