The nursing shortage: Why is it happening?

STAFFING

The headlines say it all. Reports in newspapers and magazines and on TV, the radio, and the Internet warn that the current shortages of healthcare workers, nurses in particular, have become an international crisis. Unlike past shortages, this round of shortage is global, shows no sign

Although nursing represents the greatest number of the healthcare staffing shortage, it is by no means the only area experiencing the problem. The U.S. Department of Health and Human Services reported that 90 percent of nursing homes are experiencing staff shortages (St. Louis Post-Dispatch 2002). In addition, a recent survey listed the top five healthcare positions affected by the shortage: imaging technicians, with 12.3 percent vacancy; RNs, with 13 percent vacancy; LPNs, with 12.9 percent vacancy; pharmacists, with 12.7 percent vacancy; and nursing assistants, with 12 percent vacancy (Tieman 2002). Shortages in other healthcare fields are noteworthy, but because the nursing shortage is so large and may be felt more acutely by healthcare consumers, this column will focus on the nursing shortage.

In March 2001, there were just under 2.7 million registered nurses in the U.S., 2.2 million of whom actively work in various healthcare settings. Although the number of registered nurses is up by 86,000, from the 2.1 million nurses who were licensed in 1996, demand is outpacing supply (Fitch IBCA Duff & Phelps 2001). In February 2002, more than one in seven hospitals reported that they did not have enough registered nurses (Tieman 2002). By 2010, a shortage of 1 million nurses is estimated, and by the year 2020, that shortage is expected to increase to 1.5 million (Fitch IBCA Duff & Phelps 2001).

Compounding these alarming figures is the fact that nurses and healthcare consumers are aging. In the 1970s the average age of nurses was 31, but today the average age is 46. Nearly 70 percent of nurses today are over 40, and only 9 percent of all registered nurses are under 30 (Selis 2000). From 1995 to 1998, the number of nursing school enrollees decreased by 20.9 percent (Carpenter 2000). In the next 15 to 20 years, some 76 million baby boomers will reach retirement age, creating an unprecedented demand for healthcare services. It's obvious that we need to make some changes (and frankly, I'm concerned because I happen to be a fraction older than the oldest boomers!). If we don't, a nursing shortage could become one of the most significant crises of the early twenty-first century.

Before we can answer the question "What are we going to do about the nursing shortage?" we first must find the answer to another question: "What is causing this shortage?" Some of these answers are listed below.

1. Lack of respect. One of the main answers can be found in the old quip by comedian Rodney Dangerfield: "I can't get no respect." A career in nursing, historically, was not respected. In the 1950s, a lot of women went into nursing because not a lot of career options were available to them. Nurses, who were usually women in those days, were viewed by society as handmaidens of usually male doctors, rather than as competent professionals. The birth of feminism in the 1960s made women question and reconsider the nursing career: Why become a nurse when you can get better pay, encounter less stress, and earn more respect pursuing other professional careers? With so many career options open to women today, even the women who have chosen to stay in nursing often steer their daughters away from the profession and encourage them to pursue careers in other areas such as medicine or biotechnology. According to an American Hospital Association report, Reality Check III, which surveyed younger nurses, mid-career nurses, and older nurses, only a few nurses in any of these three categories said they would recommend a nursing career to young people (American Hospital Association 1999). The good news is that men are entering the nursing profession. The bad news is that they still make up less than 6 percent of all nurses (FirstGov for Seniors 2002), and gaining respect as a nurse is as much of an issue for men as it is for women.

2. Unwelcoming culture. The hospital environment is not always welcoming to young nurses. Older hospital nurses resent the fact that the younger nurses seem to not want to "pay their dues" by working nights and weekends as they (the older nurses) had to. Sometimes the younger nurses give up because they are intimidated by their older counterparts. In Reality Check III, younger nurses talked freely about leaving the hospital setting as soon as they gained sufficient experience (American Hospital Association 1999). Having this culture of destructive competition between employees is an issue we as an industry need to address.

3. Too much paperwork. One of the main reasons women and men go into nursing is to take care of people, but nurses nowadays spend less time with patients. Reality Check III contains this quote from a registered nurse: "As a nurse, my primary job now is to document. I don't even touch patients. I am responsible for them, but it is all (about) documentation. It is not nursing at all" (American Hospital Association 1999). Another source indicates that every hour an acute care nurse spends caring for a patient requires 36 minutes of filling out paperwork, while an emergency care nurse is required to do one hour of paperwork for each hour he or she provides care (Selvam 2001).

4. Alternative settings. Home health, HMOs, pharmaceutical companies, and recruitment firms offer attractive alternatives to a hospital setting. Often these settings offer more flexible hours and higher compensation and are less stressful than hospitals. Some older nurses prefer to work in settings where they do little physical exertion, such as at a call center where they can still provide care and guidance over the phone.

5. Limited funds. Because most hospitals operate at break-even profitability, they do not have extra funds available to hire more nurses as the demand increases. This increased demand and limited-hiring-because-of-limited-funds combination creates additional work for nurses on the units; hence, it creates more stress and frustration. It also raises questions about quality of care. A growing number of industry watchers are worried that inadequate nurse staffing is putting patients at risk. Fearing that patients in hospitals with the fewest registered nurses are more likely to develop complications than patients at hospitals with more registered nurses, the state of California has mandated minimum nurse-to-patient ratios for all its hospitals, and other states are looking into similar action (California Nurses Association 2002).

With all these factors working in concert, what's a hospital executive to do? The very first line of defense is to hang on to the nurses who are already in healthcare and then concentrate on attracting young people to nursing careers. The way to do this is to radically change our organizations to meet the needs of nurses, not to find nurses who will accommodate ours.

In the next column, I will present some recommendations on combating the nursing shortage and slowing the departure of nurses. These recommendations were offered by human resource professionals and nursing leaders at a summit convened by SSM Health Care in 2000. Although these recommendations are specific to our organization's needs, they can serve as general guidelines to those who are facing the issue of nursing shortage.