Aging Nursing Workforce

Between 1983 and 1998 the average age of working RNs increased more than 4 years, from 37 to 42, according to an article by Peter Buerhaus and colleagues, published last year in the Journal of the American Medical Association.⁴ During the same period, the proportion of the RN workforce younger than 30 years decreased from 30 percent to 12 percent, and the number of working nurses younger than 30 years decreased by 41 percent. The authors contend that over the next two decades, this trend will continue and that the largest cohorts of RNs will be between 50 and 69 years of age. The total number of FTE RNs per capita is forecast to peak around the year 2007 and decline steadily thereafter as the members of this cohort retire.

By 2020, Buerhaus and colleagues predict, the RN workforce will be roughly the same size as it is today, declining nearly 20 percent below projected RN work-force requirements. Unless the trend is reversed, they say, the RN workforce will continue to age and will eventually shrink. The impending critical shortage of RNs will come at a time when the first wave of baby boomers begin to retire, qualifying for coverage under the Medicare program beginning in 2010.

Changing Requirements

Educators, employers, and others are recognizing the need for changes in nurse education to meet the nation’s health care and health promotion needs. As of March 2000, the RN workforce included 22 percent with diplomas, 34 percent with associate degrees, 33 percent with baccalaureate degrees, and 10 percent with master’s or Ph.D. degrees.⁵ Most observers agree that the increasing complexity of health care argues for a redistribution of these levels of training. In fact, nursing schools have already been evaluating and revising their curricula. For example, diploma programs, once based on an apprenticeship model, have evolved to include some college course work.

Nursing School Enrollments

Nursing school enrollments have shrunk across the nation in recent years as many potential applicants have looked to other careers. According to the AACN, enrollments of nursing students in entry-level bachelor’s degree programs fell by 6.6 percent in 1997, 5.5 percent in 1998, and 4.6 percent in fall 1999.⁶ In addition, data from the NLN indicate declines in enrollments in all types of entry-level nursing programs. Recent data from the AACN shows that enrollment continued to decrease in 2000, but at a slower rate.⁷ The decline in bachelor’s degree enrollments is in sharp contrast to the health system’s escalating demand for baccalaureate and graduate prepared nurses.

Nurse Faculty and Training

Exacerbating the nursing shortage overall are inadequate numbers of doctorally prepared nursing faculty.⁸ Although faculty shortages do not exist nationwide, they are acute in certain states and localities. Ironically, lower enrollment can be a contributor to, as well as an outcome of, such shortages. As Pamela Watson, chair of the Department of Nursing at Thomas Jefferson University in Philadelphia, states, “Lower enrollment equals less revenue equals less faculty.”⁹

The AACN reports that over the years applicant numbers are expected to increase as word of the growing demand for nurses spreads. However, educators warn that there may not be enough teachers available to train the needed nursing workforce and that schools face a number of barriers to attracting the faculty they need. For example, doctorally prepared, full-time nursing professors at four-year colleges and universities earn comparatively lower salaries (an average of $66,132 in 1998–99) than their peers elsewhere on campus. Other barriers include insufficient numbers of doctorally prepared faculty willing to teach and, especially for clinical faculty, difficult working conditions that include a heavy workload and long working hours.

Moreover, while several schools whose enrollments declined point to decreased number of applicants, others report their student shortfalls were due to intentional cutbacks because of faculty shortages, increased competition with other schools for clinical training sites, or other resource constraints.¹⁰

Managed Care

Managed care has been looked upon as a key component in the latest nursing shortage. The shift to managed care has been a factor influencing a decrease in hospital admissions for inpatient stays. While an overall decrease in inpatient hospital population might reflect a decreased need for nurses working in hospitals, a higher concentration of more acutely ill patients requires a higher concentration of highly skilled nurses. Thus, although the supply may meet demand in terms of overall numbers, the supply of nurses with strong science backgrounds and knowledge of new technology does not.

Buerhaus and Douglas Staiger suggest that managed care has adversely affected the employment and earnings of nurses nationwide. “In particular, it appears that managed care has reduced demand for RNs, initially in hospitals and more recently in home health, and as a result has led to a decline in RN earnings.”¹¹ However, clear patterns are emerging that show increased demand for RNs across all sectors, presaging a positive effect on RN employment and earnings.

Hospitals

Hospitals continue to make up the largest sector of the nurse labor market, particularly for RNs. The authors of a study reported in the January-February 1999 edition of Health Affairs assert that a change in employment growth in this sector will have a disproportionate effect on overall employment and earnings trends.

The trends since 1994 in high HMO states show little growth in hospital employment of RNs. On the other hand, very recent evidence suggests that hospital employment of RNs may be growing once more in the high HMO states. Between 1996 and 1997 employment grew 8.2 percent in the states with high HMO enrollment, with much of this growth coming from hospital employment. At the same time, in 1998 there were a number of reports of RN shortages throughout the country, suggesting that hospitals may be beginning to increase the size and elevate the skill of their nursing staffs.¹²

The authors also report that one possibility for the recent upturn in RN employment is that the slowdown in RN employment growth was temporary as hospitals passed through a transitional period in which they downsized to improve efficiency. The recent increase in RN employment might also represent a short-term correction for past cuts. “Hospitals may have scaled back the number of RNs and reduced the skill mix of nursing personnel to a point at which it was no longer possible to appropriately treat a growing number of older and acutely ill patients.”¹³

Hospitals cannot address the current shortage as easily as they could past shortages because many are financially weaker than they have been in years. According to a recent report by Mary Jaklevic and Ed Lovern in Modern Healthcare, hospitals reduced their reliance on RNs after the shortage of the mid-1980s and have few places left to cut.¹⁴ The authors argue that hospitals are competing with medical groups, insurers, and dot-coms for a shrinking pool of qualified nurses. “Nurses’ salaries are hospitals’ largest expense, constituting approximately 20 percent of their budgets. However, this budget is expected to increase as hospitals boost compensation and increase their use of temporary staffing agencies.”¹⁵

Any strategy a hospital may use for dealing with the nursing shortage has a price. According to the report in Modern Healthcare, Baptist Health, a four-hospital system in Jacksonville, Florida, is spending $4 million this year on a program that focuses largely on increasing pay for current nurses. In an effort to attract nurses to their staffs, more hospitals find themselves in bidding wars. It is estimated that as many as two-thirds of hospitals offer nurses signing bonuses, some as high as $8,000.¹⁶ Temporary staffing agencies are also being utilized more by the industry to supplement RN staffing.

Other Settings

The slowdown of RN employment in many hospitals has been accompanied by an increase in RN employment in nonhospital settings such as home health care and long-term care. According to Buerhaus and colleagues, employment in these settings grew in the 1990s, but a slowdown in RN employment has become more evident. However, as demand increases for RNs, patterns are now emerging that show nonhospital settings are also experiencing a shortage, as both hospital and nonhospital settings compete for the same pool of qualified individuals.

Improved Nursing School Enrollment

Geraldine Bednash of the AACN argues that attracting a cadre of young, college-bound students will require reform in nursing education and in the licensure and certification mechanisms used to grant practice to RNs with different educational preparation.¹⁷

In a recent survey by the AACN, deans of nursing schools identified some proven methods to increase enrollment in baccalaureate programs.¹⁸ These approaches include the following:

• Recruiting from within: Encouraging associate-degree nursing and hospital-based diploma graduates to continue their education.
• Advertising and promotion: Using media and promotional outlets to advance messages about the schools’ particular academic programs and about the rewards of a nursing career.
• Priming the early pipeline: Directing the message that nursing is a rewarding career to younger groups by sponsoring programs such as a nursing camp in Allentown, Pennsylvania; offering college credit courses on teaching institutions’ campuses to high school students; and conducting career days at elementary schools.
• Targeting underrepresented and nontraditional groups: Stepping up efforts to provide tutoring in English as a second language, mentoring programs targeting minority high schoolers, linking with historically black colleges, and reaching out to men.
• Hiring dedicated recruiters: Hiring experienced inhouse recruiters to help find adequate numbers of qualified applicants to fill empty slots.
• Improving financial aid: Finding ways to build creative financial aid packages that pay off, despite tight school budgets.
• Enhancing distance learning: Taking advantage of distance learning programs that have positive effects on enrollments.
• Polishing the image of nursing: Developing programs to educate high school counselors about nursing roles and careers to support the reality that nursing is a knowledge-based, highly skilled profession that changes people’s lives through health promotion, disease prevention, and making people’s lives better during illness.

Unlicensed Assistive Personnel

One solution the industry has used to maximize productivity while decreasing costs has been to put unlicensed assistive personnel (UAPs) into the staff mix. These staffers, sometimes called care extenders, nursing assistants, or patient care technicians, can be trained to perform tasks that nurses would otherwise have to perform but at a lower cost. However, there are risks associated with giving UAPs nursing functions. Some tasks should or must be performed by licensed nurses, according to facility guidelines, state laws, and medically accepted procedures. Further, employing too many UAPs may strain the surveillance capabilities of RNs, who are responsible for delegating tasks to UAPs and evaluating the outcomes of the tasks performed.

Foreign Nurses

Immigration of foreign RNs educated outside of the United States is also a strategy being employed. Immigrant nurses are often recruited from English-speaking countries such as England, Canada, South Africa, Australia, and the Philippines. Buerhaus and colleagues note, however, that “eliminating the projected shortage would require immigration on an unprecedented scale, and such a policy would not be without controversy.”¹⁹

The Nurse Relief for Disadvantaged Areas Act (P.L. 106–95) provides temporary nonimmigrant visas for up to 500 nurses a year. According to chief sponsor Rep. Bobby Rush (D-Ill.), the law, to expire in four years, would “assist the under-served communities of this nation by providing adequate health care for their residents.” A 1989 law (P.L. 101–238) that granted temporary visas to foreign nurses because of the shortage at the time expired in 1997.

Temporary Nurses

Recently there has been an increased dependency on temporary nurses in hospitals. These may be nurses without specialized training who “float” into critical care units or nurses hired on a daily basis from nursing registries. Hospitals, particularly chain hospitals, also hire travel nurses, who work a limited number of months before shifting elsewhere to their next assignment. Because of both trends, full-time nurses say they increasingly work with nurses who are not permanently assigned to their units.²⁰

According to Jaklevic and Lovern, Cross Country TravCor, one of the nation’s largest medical staffing companies, says it is trying to fill more than 14,000 open positions, mostly RNs in acute-care hospitals around the country, more than double the openings a year ago.

In response to the growing demand for nurses, Cross Country and other agencies like them began upping the ante this fall, offering a more comprehensive benefit package, and high pay to recruit nurses to a work life that typically involves traveling to a hospital in another city and working 13-week stints. In addition to accepting costs for bringing in agency nurses, several hospital executives say those nurses bring a quality risk simply because they are not as familiar with the particular hospital setting as their own staff nurses.²¹

Work Standards

Addressing the conditions under which nurses work is another approach. Every day, nurses in hospitals across the country work up to 16-hour shifts, putting themselves and their patients at increased risk of error and injury. In the case of nurses, mandatory overtime is a calculated business practice used by hospital administrators as a quick fix to a nurse staffing shortage.²² Congress is playing a part in addressing the issue of endangered patient safety that can occur as a result of unsafe staffing practices. A bill (H.R. 1289) that was introduced in the House would limit the number of hours licensed health care workers, including RNs, can be required to work. This bill, known as the Registered Nurses and Patients Protection Act, is sponsored by Rep. Tom Lantos (D-Calif.) and would amend the Fair Labor Standards Act so that no RN would be required to work beyond eight hours in any workday or 80 hours in any 14-day work period.

Speakers

Marla Salmon, R.N., Sc.D., F.A.A.N., will begin the session with an overview of the nursing shortage. She is dean of the Nell Hodgson Woodruff School of Nursing at Emory University where she is also a professor of both nursing and public health. Salmon joined the Emory faculty after serving as professor and graduate dean of the School of Nursing at the University of Pennsylvania where she was responsible for both master’s and doctoral nursing programs. Prior to that, Salmon was director of the Division of Nursing, HRSA, for the DHHS, leading the principal federal programs aimed at shaping the nation’s nursing workforce. In her national leadership roles, Salmon has been involved in a number of principal advisory groups, including the White House Task Force on Health Care Reform. She was also the chair of the National Advisory Council on Nurse Education and Practice.

Maryann F. Fralic, R.N., Dr.PH., F.A.A.N., will discuss strategies for addressing the nursing shortage from the perspective of private industry. She is professor and director, corporate and foundation relations, for the Johns Hopkins University School of Nursing. She also serves as executive advisor for the Nursing Executive Center of the Advisory Board and as Senior Consultant for the Robert Wood Johnson Nurse Executive Fellows Program. Fralic was formerly vice president for nursing, Johns Hopkins Hospital, and associate dean for the university’s School of Nursing. She served as senior vice president, nursing, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, and clinical associate dean, Rutgers University College of Nursing.

Raymond Grady will provide the hospital management perspective in addressing the nursing shortage. Grady is president and chief executive officer of Evanston Hospital and serves as president of the Hospitals and Clinics Division for Evanston Northwestern Healthcare. A member of the American Hospital Association (AHA) commission on workforce for hospitals and health systems, he is also a fellow in the American College of Healthcare Executives and served as the AHA commissioner to the Accrediting Commis sion on Education and Health Services Administration for seven years. He served as chair of the Accrediting Commission from 1997 to 1998.

Margaret Hegge, R.N., Ed.D., will provide a state perspective of the nursing shortage and discuss the Colleagues in Caring program, a national initiative to help states and regions build the nurse workforce. Hegge is director of academic evaluation and assessment, South Dakota State University, and directs the university’s Colleagues in Caring Grant for Nursing Workforce Development. Colleagues in Caring is a project sponsored by the Robert Wood Johnson Foundation and the American Association of Colleges of Nurses. She has authored various publications and recently received the South Dakota Nurses Association President’s Award.