| by | Brenda Nevidjon, RN, MSN
Jeanette Ives Erickson, RN, MS, CNA
Program code: EDII: 2010998 |
For additional resources on the nursing shortage, see the following publications, both of which can be purchased online:
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Table of Contents
However, these solutions are already
gaining in popularity again as evidenced by ads in local newspapers. The
solutions to create a sustained improvement to the nursing shortage will
need to be more radical than past shortages and must address many
long-term issues.
Past economic solutions such as sign-on
bonuses, relocation coverage, or new premium packages will have
limited and temporary effect because they simply redistribute the
supply of nurses, not increase it.
In addition to the worsening nurse shortage is the shortage of other staff including various allied health professionals, secretaries, and support staff. The shortages of other staff are adversely impacting nurses who have the most continuous and closest relationship with patients and their families. In the early 90's, for cost cutting reasons, there was an increased use of unlicensed assistive personnel. However, these models have failed due to increasing patient acuities, the concerns over medical errors, and the declining numbers of ancillary personnel.
Approximately one third of the nursing workforce is over 50 years of age and the average age of full time nursing faculty is 49 years. A study published in the July, 2000, issue of JAMA predicts that 40% of nurses by 2010 will be 50 years old or older (Buerhaus, 2000a ). The challenge is for redesign of patient care delivery models that are built to support the practice of an older workforce. Nursing, a physically demanding profession, must address this challenge by initializing new technology into practice. Hospitals must support the aging nurse by offering flexibility in scheduling, increased time off, and sabbaticals.
In a Lexis/Nexis review of 6 months of news articles throughout the United States about the nursing shortage, every story noted the need for creative strategies. Disappointingly, few described any new interventions. The purpose of this article is to review several factors contributing to the shortage and present possible strategies to address them. The authors have chosen to review: trends in the general work environment, image of nursing, recruitment of students, retention of current nurses, and regulatory and policy issues. Solutions, some already underway in the U.S. are highlighted. Primary nursing and Patient Focused Care are discussed and a preferred model of care is described. They hope that this article will create a rapid communication of ideas to colleagues and stimulate others to build upon these ideas.
Trends to Consider
The general work environment in the U.S. is different than at the time
of the last shortage and needs to be taken into consideration when
developing strategies to manage the shortage. There is blurring between
what has been the traditional role of manager and the managed and between
work and home. Rapid technological advances are changing the way in which
work has been done. Organizations in all industries are dealing with a
tight labor market and competing aggressively to hire the best and
brightest. The following trends affect all work environments and provide a
context in which the nursing shortage is evolving (Hymowitz, 2000; Lancaster, 1999; Shellenbarger, 1999 ). Given these trends, the following sections present the issues
influencing the nursing shortage and describe potential solutions
including efforts underway for addressing the shortage.
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Annually, the nursing profession ranks very high as a trusted profession in the U.S., above physicians and other healthcare workers. |
Like other predominantly female professions, the public undervalues nursing. While the public indicates high trust of nurses, there is a lack of understanding about what nurses do. Often, the role of a nurse is defined in relation to the physician and may still carry the image of "handmaiden." This lowered status has implications for other indicators of the "value" of nursing to society: the funding provided for nursing education, the compensation nurses receive related to the responsibilities of the job, and the work environments that nurses endure. Solution: Central to this issue is the need to revise how nurses are valued. Initiatives at the local level can affect the compensation and work environment issues and will be addressed later. Increased funding for education needs both local and national attention as discussed later.
Nurses also shape the impression that others have about the profession. For instance, they may discourage children regarding nursing as a career choice. Nurses frequently report that they do not encourage their own children to consider nursing as a career. This is quite different than the message that doctors or lawyers give to children. In social settings, nurses may complain about their work or diminish their actions, rather than bragging about or promoting their contributions to individuals and organizations. Solution: As simple as it sounds, all nurses need to be aware of the way in which they discuss their work in public.
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Nurse executives can be helpful by starting an organizational campaign to educate their staff about how to communicate in social and community settings. Each nurse is the most important recruiter for an organization. |
Currently, there is an opportunity for individual nurses and nursing organizations to recreate the public image of nursing, to help the community understand the importance of an adequate supply of well educated nurses, and to entice young people to consider the profession. Solution: Rather than having competing advertising campaigns for nurses, healthcare organizations could combine their resources and develop strategies to elevate the image of nursing. In a recent initiative, the University of Maryland School of Nursing has shown there is opportunity to partner with public relations firms to accomplish this. This school is partnering with Gilden Advertising, who is donating $1.2 million in cash, services and in-kind gifts, to launch an integrated marketing plan to recruit more students into nursing. (University of Maryland School of Nursing Press Release, 2000 ).
Recruitment of Students
For several years, enrollment in schools of nursing has been
decreasing. According to the American Association of Colleges of Nursing's
website (www.aacn.nche.edu/ ),
enrollments in bachelor's degree programs have declined for five years.
The most recent data, for fall 1999, showed a 4.6% decline in enrollment
and occurred in every region. Enrollment also declined by 1.9% in master's
degree programs but not uniformly across the regions. Many reasons explain the continual decrease in enrollment in basic
nursing programs. First and foremost is the fact that women have many
choices today when selecting a post high school education and career. Work
conditions such as evening, night, and weekend shifts, or the exposure to
contagious elements are cited as reasons that young people do not perceive
nursing as a positive career choice. The current nursing shortage has its roots in events of the 1990's. In
the early 1990's, health care futurists were predicting a reduction in the
number of hospital beds due to managed care penetration. Health care
executives in all states watched the market changes in California in
anticipation that capitation would be seen throughout the country. The
nursing profession began to brace for an era of downsizing as hospitals
were attempting to drive costs down by decreasing a patient's length of
stay and adjusting their staffing models. A plan promoted by health care
consultants was to reduce budgets by deploying assistive personnel where
nurses once practiced. This resulted in layoffs of nurses in some parts of
the country. The skill mix changes and movement of patients from acute
care to homecare or ambulatory settings forced many nurses to evaluate
their personal decisions. Feeling devalued and disenfranchised, nurses
left the profession of nursing. Thus, schools of nursing and prospective
nursing student candidates were left with an impression that fewer nurses
would be needed in the future. A compounding factor in many nursing schools is the availability of
nursing faculty. They, like nurses in healthcare delivery, are aging.
Thus, for some schools, even if they could recruit more students, they may
not have faculty to teach them. Similar issues contribute to the shortage
of faculty: compensation, cost of advanced preparation, and work
conditions.
Solution: Are there ways in which the aging practicing
nurse who can no longer manage the physical demands of the job can be used
to educate new nurses? One concern about practicing nurses is that they do
not have curriculum development and performance measurement skills. If
this is a barrier for recruiting needed faculty, solutions should
possible. New models of education are needed as acutely as new models of
patient care delivery. Practice and education have a long history of not
being aligned. Perhaps the conditions now exist to unite practice and
education, to have each earnestly listen to the other, and to enable them
to design solutions together. Strategies to recruit students are needed for the long term since the
predictions are for a worsening shortage over the next decade, but there
are immediate interventions possible. Many efforts are underway to recruit
high school students.
Solution: In San Diego, six hospital systems
have committed $1.3 million to support a program called, "Nurses Now",
which will add faculty and additional student slots to San Diego
University (Kucher, 2000 ). The
American Hospital Association News reports that in
Laredo, Texas, a hospital CEO worked with Texas A&M University to
develop a four-year bachelor's program and is providing $425,000 in
scholarships to local students over the next five years (Runy, 2000). In Morris County, New Jersey, the Board of Freeholders offered
scholarships to students who agreed to work in a long term care facility
(Cichowski, 2000). The Dallas-Fort Worth Hospital Council raised $600,000 to
expand student enrollment at local schools (Yednak, 2000 ). These are examples of various successful collaborative efforts
among healthcare organizations, government, nursing associations and
nursing schools. Many more are happening at the local level. Within the general student recruitment initiates are efforts to reach
minority students and young men.
Solutions: Hodgman (1999 )
was project director of
Choose Nursing!© , a state, privately, and
federally funded project designed to recruit Boston public high school
sophomores into a comprehensive 2 year hospital program to foster and
maintain their interest in nursing and prepare them to apply to collegiate
nursing programs. Departments of nursing or specialty organizations could
implement variations of this program. For instance, a local chapter of a
national specialty organization could "adopt" a middle or high school and
establish an outreach program with students. To ensure a continuous robust pool of nursing students, children must
be reached earlier than high school. In fact, educators say that students
often have their minds made up by fifth grade about desirable and
undesirable careers. Thus, an early positive image of nursing for students
is important.
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To ensure a continuous robust pool of nursing students, children must be reached earlier than high school. In fact, educators say that students often have their minds made up by fifth grade about desirable and undesirable careers. |
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Organizations that give attention to the employee market and understand what people are seeking from the work environment have a better chance to recruit and retain top talent... |
In a more recent study, McNeese-Smith (1999 ) investigated staff nurse descriptions of job satisfaction and dissatisfaction. For the nurses in the study, salary and benefits were important but mentioned only briefly. A key finding was that the nurses in their study found satisfaction from direct care, yet their role was changing to be the organizer and coordinator of care. Another finding with implications for administrators was that those nurses who provide poor care, have a negative attitude, or are burned out create dissatisfaction for their co-workers. Solution. Administrators and educators must learn what the satisfiers are for staff. When roles are redefined, they must help staff identify new satisfiers. Human resource administrators must be responsive to the individuality of what is important to staff and create flexible and supportive policies and benefits.
Currently, there are critical needs for experienced nurses in the operating room, critical care, and neonatal care arenas. Solution: Hospitals are reintroducing intensive training programs for nurses in these specialties. This helps to retain nurses who are looking for a transfer opportunity as well as to recruit new staff. It also builds a career development path for staff. These training programs are not inexpensive and nursing leaders must be prepared to justify the required budget. Given the cost of temporary staff, this should be a logical solution for the organization's leadership to endorse.
For at least two decades, the literature has promoted the notion that shared governance/shared leadership creates a more satisfying work environment. The research that has been done on magnet hospitals shows that organizational characteristics that attract and retain nurses include professional practice models for delivery of care with autonomy and responsibility for decision-making. Participatory management, enhanced communication, and adequate staffing were relevant features of hospitals that nurses identified as good employers. While few hospitals have Magnet status, the research remains relevant and applicable. Solution: Effective administrative structure, quality patient care, and investment in professional development of nurses are important. Staff must be involved in defining and developing the practice of care in the organization since they are the closest to the patient. This includes participation in the financial management of their unit.
Models of Care
One challenge for nursing will be to address the viability of primary
nursing. (Note: italics denote
changes made March 2001) While current perspectives and applications of primary
nursing are absent from the literature, two editorials published in the
Journal of Professional Nursing by Joyce Clifford of Beth Israel, Boston (1988) and Kathleen Andreoli of Rush Presbyterian/St.Lukes, Chicago (1992) remain valid.
Clifford (1988) began her piece by challenging the statement that "Primary
Nursing is dead." She argues that "Primary Nursing is alive and well." Why
the confusion? She asserts that it is not always clearly understood that
the development of primary nursing and a professional practice model comes
from a strong philosophical commitment rather than merely from the
understanding of a nurse-patient assignment method.
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It is this relationship with patients that must be preserved for the future if a balance is to be struck between the goals of cost and quality in health care. |
Clifford (1988) notes that time has shown that nurses will no longer accept the mere performance of tasks as their practice goal outcomes. Nor will they remain in systems that promote fragmented, uncoordinated care leading to dissatisfaction for everyone - the patient, nurse, and hospital. Instead, nurses seek opportunities to provide comprehensive, professional care through a system that allows for continuity of patient care as well as the opportunity for them to maximize their knowledge and skill. The change they made from a functional/team delivery system of care to a system that provides for a comprehensive, coordinated approach to patient care required the best prepared, i.e., the registered nurse, rather than the least prepared to be placed in the most direct and constant care relationship with patients and families. It is this relationship with patients that must be preserved for the future if a balance is to be struck between the goals of cost and quality in health care. This nurse-patient relationship is, of course, the underlying principle of primary nursing.
In the early 1990's, management consultants advocated for the development of a model called Patient Focused Care. However, for many, this model resulted in an increase of nursing aides and a decrease of professional nurses. Andreoli (1992 ) identifies the 1990's as the decade of ideal nursing skill mixes and delegation. Nurses must know what tasks are appropriate to "give away," how to manage the workload and be accountable for outcomes, and how to provide for the growth and development of non-RN caregivers and other support staff. Andreoli envisioned that this change would not come easily, and, it hasn't. Nurses sometimes feel less valued when they must delegate tasks to a non-nurse. However, nursing can consider delegation, along with shared governance, as another form of empowerment.
Delegation, though, must be learned, practiced, evaluated, and improved. Delegation is an art, and the delegator must have an understanding of the essentials of management, chain of command, span of control, licensed versus unlicensed assistive personnel, nursing task versus professional responsibilities, liabilities, mentorship, evaluation, and continuous quality improvement. Andreoli stresses that in a successful delegation model, primary nurses will have time to give patients the benefit of their knowledge and skills. Tasks not requiring a nurse's educational preparation will be delegated to qualified assistive personnel. Nursing leadership must create an environment where delegation is supported and valued and positive outcomes are rewarded. The patient then is the winner with the best of both types of providers.
Numerous studies on delivery models and restructuring demonstrate that different staff mixes and approaches work in different settings. There isn't a "one size fits all" model. However, what must remain constant is the guarantee that every patient has a nurse.
An example of a futuristic model of care was developed at the Massachusetts General Hospital and presented as a Harvard Business School case study (1999). Similar to almost every other healthcare institution in America, this system of care delivery emerged after careful reflection on many factors: the local and national labor market, the changing profile of patients served, the nature of the workforce, and the systems or infrastructure that supported practice. The Massachusetts General Hospital Patient Care Delivery Model (Figure 1 ) was derived after careful development of vision, values and long-range goals. In this model vision, values and goals converge to support the delivery of patient care. The model depicts the dynamic and therapeutic interaction that occurs between the professional care provider and the patient around issues of health and illness. The model reflects an open, evolving interactive system where there is continuous exchange occurring between the patient and the clinician (nurse, therapist, or social worker). The model also depicts the multiple internal and external forces that impact upon the patient's experience as well as the structures supporting the delivery of patient care.
EXTERNAL HEALTH CARE ENVIRONMENT
The larger, important circle surrounding the core represents the interdisciplinary partnerships within the multiple settings where patient care is delivered. This is an important message for staff nurses who feel supported in their practice by all team members. While this is an example of one model that considered internal and external factors, it does reflect the elements that must be considered during this time of a structural shortage of healthcare workers.
Again, this shortage is different and most likely not cyclical in nature. In any model a balance must be struck between: a) supply and demand, b) quality and organizational effectiveness, c) staff satisfaction, and d) financial viability.
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As nursing organizations such as the American Nurses Association lobby for increased federal funding, individual nurses need to respond to the request for communication with their elected officials. Every nurse must become a vocal proponent of increased funding for nursing and educate their representatives that nursing is the necessary glue in health care.. |
A recruitment strategy that has been successful in the past and is being used again is the employment of foreign nurses. Hoping that this may be a solution, many are raising the question about reviewing federal policy regarding visas for foreign nurses. Currently, the federal policy is a barrier for recruitment of nurses from other countries. However, many countries, Canada for one, are also experiencing a shortage of nurses and this strategy may not help. In fact, many are predicting that there is an emerging global shortage of nurses.
State Boards of Nursing also have an important contribution to make during this uncertain time regarding both the recruitment of nurses and retention of nurses. No doubt, there will be pressure to lower licensure standards to increase the number of graduate nurses. This would be a mistake as the Boards are responsible for protecting the public from unsafe, illegal or unethical practice. During times of shortage and stress, the potential for unsafe practice may be heightened. However, Boards need to review also their policies and procedures to determine whether those policies and procedures are contemporary or out of date and contributing to the nursing shortage. Another topic of great discussion is that of assistive personnel. As hospitals have increased their use of assistive personnel, many registered nurses have not been willing to remain on staff and supervise care of other providers. The Boards of Nursing define the scope of nursing practice and what can be delegated to others and should be helping to educate nurses about this issue. Also, rather than viewing delegation as promoting fragmentation of care, definition needs to be given as to how care can be enhanced by using the full capabilities of registered nurses. The American Nurses Association's position statement on maintaining professional and legal standards during shortages is useful to read in this regard (ANA Board of Directors, 1992 ).
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Table 1. Recommended Websites Discussing the Nursing Shortage |
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American Nurses' Association | www.nursingworld.org/ |
| Nurses for a Healthier Tomorrow | www.nursesource.org/ |
| Nursing Economics | www.ajj.com/ |
| The Forum on Health Care Leadership | www.healthcareforum.org/ |
| National League of Nursing | www.nln.org/ |
| Bureau of Labor Statistics | www.bls.gov/ |
| American Hospital Association | www.aha.org/ |
| American Organization of Nurse Executives | www.aone.org |
| American Association of Colleges of Nursing | aacn.nche.edu (password required) |
| Allnurses.com | allnurses.com |
| Nurse.com | nurse.com |
| HRLive | hrlive.com/reports |
Other Websites:
Nursing Specialty Organizations |
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As reviewed in this article, key factors contributing to this shortage are: the differences in the general work environment compared to past shortages, the ongoing struggle with the image of nursing, recruitment of new nurses, retention of current nurses, and regulatory and policy decisions that can be a barrier to recruitment or a cause of attrition of nurses. Models of care delivery are also discussed. There are solutions to enact for each of those factors and some are underway. In the short term, fiscal and marketing strategies may help. Changing the work environment will be necessary, however, for both the short and long term. Ultimately, it is the long-term solution of making the profession a desirable career choice that is essential. The good news is that nursing continues to be the most trusted and respected of all the health care professions. From a demand perspective, it is one of the fastest growing professions and thus offers a strong career opportunity for today's youth. The time is right for nursing's voice to be strong with the public, with health care system leaders, and with the government. With a strong united voice, nursing may be able to use this shortage as a catalyst for creating a solid foundation for the future of the profession.
Authors
Brenda Nevidjon, MSN, RN
e-mail: Nevid001@mc.duke.edu
Brenda Nevidjon is Associate Clinical Professor in the Health Systems Leadership and Outcomes Division of Duke University School of Nursing. Previously she was Chief Operating Officer at Duke University Hospital for four years. A graduate of Duke University School of Nursing (BSN) and the University of North Carolina School of Nursing (MSN), Nevidjon's career has included work in Switzerland, Canada and Seattle in addition to Duke. She is known for her advocacy for care delivery environments that place patients and families first and that promote teamwork and recognition for staff. She has published two books, numerous book chapters and articles, and editorials on health care, cancer care, and leadership topics. She serves on several local and national boards and is a member of the American Nurses Association, the North Carolina Nurses Association, Oncology Nursing Society, and Sigma Theta Tau. She is a Johnson & Johnson/Wharton Fellow and a member of the inaugural class of the Robert Wood Johnson Executive Nurse Fellows Program.
Jeanette Ives Erickson, MS, RN, CNA
e-mail: Jiveserickson@partners.org
Jeanette Ives Erickson is Sr. Vice President for Patient Care and Chief Nurse at Massachusetts General Hospital, Assistant Professor at the Massachusetts General Hospital Institute of Health Professions, Visiting Scholar at Boston College, and a faculty member of the Institute for Nursing Healthcare Leadership. A graduate of Boston University Graduate School of Nursing, she has made significant contributions to patient care through her lectures, leadership, and professional activities. Appointed to the executive team of the MGH in 1996, she leads the institution's largest clinical division including nursing and other health professions. She is recognized for her patient advocacy, expertise in patient-care delivery model design, and multi-disciplinary professional practice models. She has authored several articles and book chapters and serves on several community boards. She is a member of the Massachusetts Organization of Nurse Executives, the American Organization of Nurse Executives, the American Nurses Association, and Sigma Theta Tau. She attended the Center for Nursing Leadership and the Leonard Davis Institute for Health Economics at the Wharton School. In 1998, she was awarded an inaugural fellowship in the Robert Wood Johnson Executive Nurse Fellows Program.
Contributing Authors and Expert Review Panel for the independent study module:
Tracey Carlson, MSN, RNC
Nurse Continuing Education Consultants:
RoAnne Dahlen-Hartfield, DNSc, RN, Center for Continuing Education and Professional Development, American Nurses Association
Peggy Doheny, PhD, RN, Kent State University, School of Nursing
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Barbara A. Dieckman, MSN, RN
Shirley A. Hemminger, MSN, RN, CCRN
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Carol Ann Sedlak, PhD, RN, ONC
Jeri L. Shaffer, MSN, RN, OCN
www.nursingworld.org/readroom/position/joint/jtshort.htm
