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The Nursing Shortage
This report was presented at the April 2001 meeting of the New York State Board of Regents.
The Nursing Shortage
This is the eighth in a series of reports to the Board of Regents on emerging issues in professional regulation. The report deals with a potential crisis that may seriously affect all New Yorkers in the next few years - the nursing shortage. Previous reports in this series include corporate practice of the professions, telepractice, cross-jurisdictional professional practice, continuing competence, effective professional regulation and discipline, illegal (unlicensed) practice of the professions, and rising consumer expectations. This report describes a fundamental health care issue that is basic to the Regents public protection mission. The critical shortage of qualified nurses projected within the next five years will have a profound effect on health care for New York's consumers well into this new century. Failure to successfully address the problem will threaten the quality and safety of the entire health care system in this State, the welfare of consumers who depend on this system for patient care, and the future of the professionals who practice within this system.
Research points to a nursing shortage that, if unaddressed, will be more severe and longer in duration than those previously experienced in New York. Several factors differentiate this shortage from previous ones, including the global nature of the shortage, an aging work force, the image of the nursing profession, the impact of managed care and/or other cost containment measures, the impact of new opportunities for women in other professions, low unemployment, the challenging work environment of nurses, and the decreasing overall population. Solutions must be varied, and they must be coordinated across organizations and agencies employing nurses as well as the entities responsible for educating and overseeing professional practice and practice environments.
This report is designed to provide an orientation to the problem and proposed solutions. It describes the shortage, explains how the shortage differs fundamentally from previous shortages, and defines the relationship between nursing education and the supply of nurses. The discussion also highlights workplace, demographic and economic factors that contribute to the impending shortage. We present for consideration a summary of recommendations to address the problem. Recommended actions include those described by the literature which are being explored by the broad health care, education and regulatory community. In addition, this report includes specific actions that the Board of Regents may consider to address the impending nurse shortage and its implications for the health care system as a whole.
THE NURSING SHORTAGE
I. The Supply of Nurses
In recent years, the nursing profession, health care administrators, government officials, the media and others have warned that a national nursing shortage of critical proportions is imminent. This report will review the evidence behind these predictions, consider contributing factors to this development, and describe what can be done to protect the public and ensure that the need for nursing services will be met.
According to a recent national survey¹, there are currently over 2.6 million registered professional nurses (RNs) in the United States, an increase of 5.4% since 1996. This is the lowest increase reported since these surveys were first conducted. Just over 2.2 million RNs are employed in nursing; of those, about 1.5 million or (71%) are practicing full time. This year, the National Sample Survey of Registered Nurses projected that by the year 2005, 2.6 million full-time practicing RNs will be needed nationally. The Federal Bureau of Labor Statistics also projects that the need for RNs will grow faster than the average for all United States occupations through 2008.
In New York State, where there are over 234,000 RNs and more than 68,900 Licensed Practical Nurses (LPNs) as of April 2001, the trend is similar to the national averages. The number of LPNs registered to practice increased by only 6% between 1997 and 1999 (to over 74,000), and has since dropped by 7% in the past two years. The number of registered RNs has grown slowly by 5% between 1997 and 2001 (to 234,820). Overall, the total number of nurses registered to practice in New York State (LPNs and RNs) grew by just over 3% between 1997 and 2001, reaching its peak in 1999.
Among the nine states within the New England and Middle Atlantic regions, according to the National Sample Survey of Registered Nurses, New York ranks next to last in the number of RNs employed per 100,000 people, with just 843 per 100,000. In contrast, 1,194 RNs are employed per 100,000 people in Massachusetts, the first state to declare a statewide nursing crisis. By 2005, projections indicate that the demand for registered nurses in New York will exceed supply by over 17,000 nurses. By 2015, that gap is expected to almost double.
While the total supply of nurses is currently adequate in some parts of the State, a convergence of factors is expected to cause an overall shortage of nurses within the decade. Already, there is an uneven distribution of the existing nurse supply, and some practice settings are experiencing a shortage now. Current shortage areas include hospital emergency departments, critical care units, and peri-operative units (units associated with pre-surgery, surgery and recovery).
These settings are the most physically demanding and require the highest level of specialized education and experience. In February 1999, 30% of hospitals in the greater New York metropolitan area reported that it takes three months or more to fill RN positions in these units. Statewide, in the fall of 2000, 92% of hospitals reported vacant RN positions and 71% reported vacant LPN positions.
¹ The Registered Nurse Population. National Sample Survey of Registered Nurses.
II. Why Is This Nursing Shortage Different From Previous Ones?
The balance in the current supply and demand for nurses varies both within and among states. While fluctuations in the supply and demand for nurses have driven periodic shortages in the last 40 years, the currently predicted shortage appears to be driven by structural factors affecting the supply of adequately prepared nurses. Just as the supply of RNs is beginning to contract, other forces, such as the growth of our elderly population, may accelerate the demand for RNs.
Veteran practitioners reading about the nursing shortage may experience a sense of déjà vu - we have been here before. Only four and a half years ago (August 19, 1996), the New York Times contained an article, Once in Big Demand, Nurses Are Targets for Hospital Cuts. The article reported that to survive in the managed care world, New York City hospitals were cutting costs through early retirement incentives and other methods, including layoffs, to reduce nursing staff. Just two and a half years later (March 23, 1999), another New York Times article alerted us that Registered Nurses (Are) in Short Supply at Hospitals Nationwide. This time, the report noted that nearly all acute-care hospitals were experiencing nursing shortages in "...operating and emergency rooms, intensive care units, and pediatric wards...."
The current shortage is different than those in the past. It is defined by several new variables, including an aging work force, increased career opportunities for women, the image of the profession, managed care and other cost containment measures, low unemployment, a shortage of nursing faculty, and a decreasing population overall. Some of these variables are unique to nursing, while others are also driving the projected declines in many other licensed professions and occupations. Combined, these and other variables render this nursing shortage uniquely challenging, necessitating new strategies for its solution.
The challenge is further complicated by the subtle distinction between "demand" and "need". From a health care standpoint, we may reasonably conclude that the aging population will need more nurses. This is not the same as the industry's demand for nurses, which is a staffing and economic concept driven by reimbursement levels and employee costs. If employers feel financially pinched, they may seek to limit their demand for nurses - apart from the needs of the aging population. As regulators entrusted with public protection, we focus on the need part of the equation. The challenge will be to align the supply, need, and economic demand as closely as possible for the benefit of New Yorkers.
III. The Factors Behind the Uneven Distribution and Shortage of Nurses
Factor: Aging Work Force
The nursing work force is aging; the current average age of registered nurses in New York State is 47, two years older than the national average. The average retirement age for nurses is 49. While no one can predict the future with absolute certainty, the data indicate that a vast exodus of nurses from the work force could occur within the next two to ten years. We need innovative strategies to address this loss, especially in an environment of decreasing supply. Between July 1990 and July 1999, New York State's population between the ages of 18 and 24 declined by 21.3%. That general statistic mirrors the condition found in nursing. In November 1980, 25.1% of employed RNs were younger than 30 years old; as of March 2000, that figure dropped to less than 10%.
As the country's 78 million "baby boomers" continue to age, more Americans will be retiring than joining the work force. By the year 2020, the total population of New York is projected to grow by 7% and the population over 65 is projected to grow by 24%.
As a result of this sweeping change in the country's demographics, work force shortages are predicted in a number of health professions - and in the work force in general. Shortages in other health care professions are likely to further contribute to the burdens facing available nurses. Projections in pharmacy, the third largest health profession, predict deepening shortages over the next five to ten years despite the opening of as many as seven new colleges of pharmacy across the country. As a result, nursing staff may have to incur additional responsibilities, such as having to mix medications that were previously prepared by pharmacists or having to pick up patient medications at the hospital pharmacy because there are no pharmacy staff to provide delivery. Nurses who are attempting to meet their patients' health care needs may be further frustrated with delays in receiving medications and reduced opportunities to easily confer with pharmacists on behalf of their patients.
Factor: Increased Career Opportunities for Women
The nursing profession is largely dominated by females - 94.6% of RNs are women. Today, women have many more career opportunities than they did just a few decades ago. Women are now pursuing many competitive, attractive, and lucrative careers that were virtually closed to them in the 1960s when "baby boomers" made their career choices. Women are entering law schools and medical schools in record numbers. They are assuming leadership posts in the corporate sector and in government. Research indicates that 35% fewer women would choose nursing as a career in the 1990s than they would have in the 1970s.
Factor: Underrepresentation of Minorities
While the nursing profession has a higher percentage of minority representation than most other licensed professions, minorities are still underrepresented among nurses, particularly RNs. Nationally, only 72% of the general population is non-minority white, and 87% of registered nurses are non-minority white. This results in only 13% of nurses being represented by minorities compared to 28% for the general population. Of those 13% minority nurses, the largest population groups are: 5% Black/African American, 4% Asian and 2% Hispanic.
As the State's population becomes increasingly diverse, the nursing work force should reflect that diversity in race, ethnicity and gender. The nursing shortage, then, reflects both a general shortfall in the number of nurses needed and in their diversity.
Factor: Previous Inaccurate Projections of Need
The present nursing shortage can be traced to the early 1990s when a reduction in the number of hospital beds was predicted due to the emerging influence of managed care. In turn, nursing education programs and potential nursing school applicants anticipated that fewer nurses would be needed in the future. Fewer people applied to nursing programs
and fewer faculty were hired.
At the same time, cost containment measures were initiated, including managed care, hospital consolidation, downsizing and financial reengineering, which resulted in shorter hospital stays and changes in staffing models. In some cases, unlicensed assistive personnel were hired to reduce budgets and nursing layoffs occurred. The changes in the level of professional staffing and the movement of patients to home care and ambulatory settings reportedly forced many nurses to reevaluate their career options. A large number of RNs left the nursing work force voluntarily or otherwise. While demand is currently escalating and hiring has intensified in a variety of settings, leading to expanded opportunities for RNs, nurses who left the nursing work force are not returning and the number of potential nursing school applicants is not increasing.
Factor: Workplace Environment of Nurses
The flip side of the increase in alternative careers is the increasing perception of nursing as a less desirable career choice. Stressful working conditions - night and weekend shifts, exposure to contagious elements, reduced time for patient care, and employer policies that push individuals to do more with less - do not project the profession of nursing as an attractive career choice, as it once was. In a recent American Nurses Association (ANA) national staffing survey, 7,300 nurses commented on their working conditions and provided their assessment of health care in America. Their remarks are revealing:
Fifty-six percent of the RNs surveyed believe that their time available for direct patient care has decreased within the last two years.
Seventy-six percent said that they experienced an increased patient-care load, resulting in a dramatic decrease in the quality of patient care provided to each patient.
Seventy-five percent of the nurses indicated that the quality of nursing care has declined in their work setting and cited examples including: inadequate staffing, delay in providing basic care, and the discharge of patients without adequate information to continue their care.
Forty-nine percent of the respondents said they feel exhausted and discouraged when they leave work; nurses reported skipping meals and breaks to care for patients, increased pressure to accomplish work, forced overtime, the inability to attend in-service continuing education programs, and increased stress-related illness.
Forty-one percent would not feel confident having someone close to them receive care in the facility in which they work.
Almost 55% of the nurses surveyed would not recommend the nursing profession as a career for their children or friends, and 23% expressed that they would actively discourage someone close to them from entering the profession.
Factor: Future Enrollments and Needs
Recent data from the National League for Nursing indicate declines in enrollments in all types of entry-level nursing programs. A study by the American Association of Colleges of Nursing found that enrollments in entry-level baccalaureate nursing programs decreased by 4.6% in 1999 and by another 2.1% in 2000; the fifth and sixth consecutive drops.
Many hospitals already require a baccalaureate degree in nursing and others have established a baccalaureate degree-preferred policy for new hires. The Veterans Administration, the nation's largest employer of RNs, has established the baccalaureate degree as the minimum preparation its nurses must have for promotion beginning in 2005. In the province of Ontario, effective January 1, 2005, all nurses seeking registration for the first time must hold a baccalaureate degree.
Factor: Shortage in Nursing Faculty
The national shortage of nurses is intricately linked to a shortage of nursing faculty. Lack of faculty will keep educational programs from producing more nursing graduates. In turn, fewer nurses will be available to choose an academic career, further increasing the faculty shortage. Nurses with graduate degrees have multiple opportunities in health care, including administrative, entrepreneurial, and clinical research positions - positions that provide more financial rewards than faculty positions.
The shortage of nursing faculty will also affect the expansion of the knowledge base for nursing practice. As the number of faculty conducting research decreases, the knowledge base behind nursing practice threatens to stagnate. In addition, the shortage of nursing faculty will limit their participation as professional leaders who help shape health and education policy in the State and in the nation.
IV. Impact of the Nursing Shortage
The nursing shortage has not yet reached a crisis level in New York State and its severity varies by geographic region and facility. Nonetheless, problems related to inadequate staffing already exist. The critical shortage of qualified nurses will have a profound effect on New York's health care for consumers well into this new century.
Effect on Hospitals
Some hospitals have been forced to close entire departments. For example, Ellis Hospital in Schenectady recently closed its maternity ward, placing an overwhelming burden on the next nearest maternity facility. In large cities, emergency rooms have been closed due to overuse and understaffing. In November 2000, nursing shortages forced Johns Hopkins Hospital in Baltimore to leave 10% of its surgical beds unfilled. The Hospital also delayed or cancelled surgeries. Flu epidemics, highway accidents, natural disasters and many other emergencies are unpredictable. Hospitals need sufficient staff to handle both expected and unexpected demands on emergency rooms and in and out patient services.
Mandatory overtime is becoming more prevalent as the nursing shortage worsens. Approximately 45% of the respondents in the previously cited American Nurses Association staffing survey indicated that their agencies were using mandatory overtime as a strategy to cover staffing demands. Nurses' concerns about their ability to provide safe care under such conditions are increasing. However, when nurses refuse to work additional hours, employers (reportedly) threaten that the nurses' actions will be reported as patient abandonment. The threat to their nursing licenses and thus their jobs, forces nurses into situations that challenge their abilities to provide competent professional services.
Testimony at a February 2001 U.S. Senate Subcommittee hearing related current staffing problems to the hesitancy of nurses to accept positions where they will not be provided appropriate staff support, but instead, will be required to work mandatory overtime, rush through patient-care activities and overlook unsafe practice by others. Georges C. Benjamin, M.D., Secretary to the Maryland Department of Health and Mental Hygiene, summarized the hearing by stating that, "There are three problems. Nurses are not coming into the profession. The ones who are there are not staying in, and those who are there are not happy."
The awareness that the negative image of the current workplace environment projected by nurses may hamper recruitment efforts has caused the President of the New York State Nurses Association recently to ask members to focus on projecting the profession of nursing in a positive manner.
Go to next post for part 2. Karen