An excellent synopsis of the situation....
The Future Nursing Workforce
By Susan King, RN, MS
Administrator, Professional Services
I recently saw an advertisement in a magazine. It was a picture of a middle-aged nurse and the caption read, Nurse Thyself. I dont remember the point of the ad or if there was a product, but it doesnt matter. What does matter is that unless we find ways to maintain an adequate nursing workforce, the caption will be our future. I dont know about you, but I want to be able to expect that nursing care will be available for me and all
those who need it now and in the future.
Right now things arent looking good for the nursing supply and considerations must target two distinct populations. First, are those of us in the profession. Next we have to think about the potential nurses who are our future.
The retention of existing professionals is a major concern to the industry. A Mercer survey in 1999 revealed that 30% of health care executives believe that nurse retention is a significant problem. In Oregon, many health care facilities are starting committees to solicit ideas about this topic. The Oregon Health Care Association, a membership organization of long-term care and assisted living facilities, has done extensive research on issues of
nurse and certified nurse assistant retention in their segment of the industry. It seems that there is no question that retention is the critical factor in dealing with the nursing shortage short-term.
What are existing nurses saying about conditions that must be changed to KEEP us?
The answers are:
Salary and benefits
Improved practice environment conditions
Quality of care
The industry is going to have to pay us significantly more and institute changes with us to support professional practice that is based on standards of care and quality. Workloads need to be managed by improved staffing and the availability of support services that preserve nursing care and reduce non-nursing responsibilities.
What do we know about our future workforce?
First, they are not going to be like the average nurse (age 46). The current literature describes our future in terms of Generation X and Y. These labels help describe a cohort of the population very different from the boomers. One study of Ohio college freshman revealed that they are optimistic, job and career-oriented and ambitious in terms of their desire to be well off.
They come less academically
prepared and have less interest in academic rigor. They want relevant coursework and more concrete experience. From other sources, we know that Gen X and Y value their work but want time off to have a life outside of their career. They are looking a little more conservative than the boomers and more careful about analyzing what is in it for them.
We know clearly that nursing has lost its competitive recruitment advantage now that women have virtually unlimited access to entry into all professions. We also know that many industries are able to attract individuals because of our booming economy that supports their generous salary and benefit packages. We also know that working conditions for all health professions have not been too great for about the last decade. How does that apply to those
who will be future nurses?
The fix to the nursing shortage to make our profession attractive to X, Y and eventually the Z generations will be comprehensive change, not quick fixes. In addition to the list of priorities that the existing workforce has already identified, let me add a few changes that will position the profession better in the future.
Maintain and Increase Practice and Education Standards
Unfortunately, nursing and the industry have reacted to previous shortages in very unwise ways. Remember the last one in the late 1980s when the issue of increased and inappropriate use of a variety of unlicensed workers was emerging as a major solution to insufficient licensed nursing staff. In previous decades, nursing has responded by instituting RN programs to produce a supply quicker. The reality is that nursing demands knowledge and skill
that must be based on sound standards and adequate preparation. Our current educational preparation needs to match the reality of practice.
Practice Setting Changes
Industry resources need to be shifted toward direct patient care. We can no longer afford to hope that the nurses and other health care professionals will be able to do more with the same or fewer staff resources. Nursing practice needs to be supported with professional recognition for credentials. Nurses must hold themselves accountable for focusing care on patient outcomes and our contribution to those outcomes must also be recognized and valued.
If there is any doubt, a good place to look to verify that this relates to recruitment and retention is in those facilities that have been granted Magnet status by the American Nurses Credentialling Center (subsidiary of ANA) as well as patient outcomes.
Profession and Industry Collaboration
The nursing profession and the health care industry have had some rocky times. Nursings criticism of hospitals, health care consulting firms andthe insurance industry have been justified, but we must learn how to work with employers and funders in new ways. It is in the best interest of our patients, ourselves and our employers, for example, to work together to reduce or eliminate inappropriate reimbursement for services. For example, why should
Oregon Medicare recipients and the institutions in which they receive care be paid less than those in Florida? Facilities and nurses can come up with great solutions to common safety problems that make hospitals and other settings less safe than they should be. We can also be great partners in cutting costs that dont really matter to patients or to the success of any organization.
Will nurses and the industry be able or willing to make the major changes necessary to ensure the survival of the profession? Time will tell but there really isnt a choice.
RN Shortage - NON-SOLUTIONS:
Mandatory overtime. Except in times of narrowly defined critical need or disaster, nurses believe that mandatory overtime is unacceptable, yet it is employed particularly in hospitals to make up for insufficient staff. Staff shortages are caused either by deliberate understaffing, vacations or inability to fill vacant positions. Overtime work has implications for safety and commission of errors as recognized by other occupations and professions. For
example, airline pilots and long haul truck drivers have limits on the
number of hours they can work, yet in health care nurses, physicians and others have no such requirements. Since fatigue is known to contribute to errors, mandatory overtime was identified as a major consideration in the profession's plan to reduce errors and increase consumer safety.
Understaffing. This has emerged as the primary concern among nurses in clinical practice because patient safety and acceptable outcomes depend on the availability of qualified professional nurses. A growing body of research supports this conclusion. Understaffing in today's hospitals is partially a remnant of the managed care influence on the system, which attempted to squeeze "fat" out of health care. Unfortunately, staff cuts were often identified
by the non-clinician administrators as that fat. Now as the system acknowledges the demand for services and the lack of wisdom applied to many of the approaches of managed care, staff numbers just aren't there.
Decreasing qualifications. This is a very old trick. Remember the AMA's brilliant registered care technician proposal? Or the ongoing interest among some health care executives to replace professionals with all sorts of lesser or untrained technicians and assistants? Now we have these old proposals dressed up to look different. The proposal in Congress to allow nursing homes to use uncertified helpers for such "simple" functions as feeding and
ambulation is an example. Another example is the demand for new or reopened LPN programs to train increased numbers of less expensive staff who carry a nursing license. Not the solution we need.
Importation of foreign nurses. Some segments of the industry suggest that the process for credentialing foreign nurses should be shortened and that barriers to obtaining visas should be eliminated. Never mentioned are the stories, such as the Texas experience, with a company that imported nurses and kept them isolated and used them as staff in long term care settings at very substandard wages. The effect on the patients wasn't good. While we have
seen the increased use of foreign workers in high tech, those industries are already doing all they can to attract our own. Foreign nurses aren't the problem but when an industry pays nurses less than electricians, it shouldn't be given free reign to import.
Interstate compacts. The interstate compact proposed by the National Council of State Boards of Nursing, which would virtually negate individual state standards for those who join, is being suggested as a way to assist segments of the industry hire more easily. In reality the ability to get nurses licensed in the state more quickly will do nothing if the practice settings are not attractive or financially rewarding.
It is easy to get discouraged when these proposals are offered as solutions to the nursing shortage. However, it isn't all bad news. There are shining examples of a different approach - one that values and supports nursing professionals to provide optimal care. Magnet hospitals, whose nursing services are based on collaboration, self-direction and high professional standards, report having far less difficulty in attracting and keeping nurses. The
industry should learn from them and needs to learn quickly that nurses aren't different from other professions and occupations.