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The American Health Care System at a Crossroads: An Overview of the American Organization of Nurse Executives Monograph

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Patricia Reid Ponte, DNSc, RN


The current nursing shortage is expected to worsen in the coming decades as the average age of working RNs rises and more RNs reach retirement age. The American Organization of Nurse Executives (AONE) has published a monograph, Perspectives on the Nursing Shortage: A Blueprint for Action, which discusses factors contributing to the current shortage and outlines steps that must be taken to ensure a nursing workforce to meet future demand. In this article, the author summarizes key elements of the AONE monograph, including the factors that contributed to the writing of this monograph, recommendations for resolving the current and impending nursing shortfall, and actions that practicing nurses can take to help ensure a robust workforce for the future.

Citation: Reid Ponte, P., (May 31, 2004). "The American Health Care System at a Crossroads: An Overview of the American Organization of Nurse Executives Monograph". Online Journal of Issues in Nursing. Vol. 9 No. 2, Manuscript 2.

DOI: 10.3912/OJIN.Vol9No02Man02

Key words: nursing shortage, nursing workforce, nursing supply, nursing demand, nurse recruitment, nursing education, government funding, American Organization of Nurse Executives, work environment

...strategic partnerships and planning among all stakeholders is essential assure that the current and future nursing shortage is averted and abated.

Nurse executives in the service sector, like academic nurse leaders, nurse researchers, and health care policy leaders, share the goal of sustaining and evolving the profession of nursing so that society benefits from the care, expertise, and compassion of the practicing nurse. Nursing shortages, which have consistently been on the radar screen of all nurse leaders, can compromise efforts to meet this goal. Often, shortages are picked up and dealt with through sector-specific or region-specific approaches. Today’s shortage has been aptly detected and recognized as very different from earlier renditions of nursing shortages and presents one overriding mandate: strategic partnerships and planning among all stakeholders is essential and must occur to assure that the current and future nursing shortage is averted and abated.

The monograph by the American Organization of Nurse Executives (AONE) (2000), Perspectives on the Nursing Shortage: A Blueprint for Action, describes collaborative tactics and mechanisms to boldly interrupt the roots of the shortage and to catalyze changes and innovations that will assure the vibrancy of the professional nurse workforce of the future. The purpose of this article is to help nurses in the clinical setting understand and respond to the AONE monograph. This article summarizes: (a) factors that led and contributed to the writing of the monograph, (b) recommendations proposed in the monograph for resolving the shortage, and (c) implications of the shortage for practicing nurses.

Factors Contributing to the Writing of the Monograph

During the late 1990s, a number of factors, including market forces, workforce demographics in a strong economy, and changes in population and technology, converged to produce a nursing shortage that experts predicted would worsen over the coming decades. These factors and their implications for the future of nursing led AONE to write and publish the monograph, Perspectives on the Nursing Shortage: A Blueprint for Action. The following paragraphs outline how the factors contributed to the nursing shortage at the time the monograph was written in 2000.

Market Forces

During the 1990s, hospital restructuring (prompted by managed care penetration and decreased health care financing) contributed to a decrease in registered nurse (RN) full time equivalents within hospital and home care settings. In many organizations, infrastructures for nursing orientation, education, and specialty training were dismantled as funding priorities in the organizations shifted away from what was perceived as non-essential programs. At the same time, wages for the RN workforce remained flat in many regions of the country, severely impacting the nursing workforce and adding to the decline in enrollment in nursing schools across the nation.

As practice environments became less appealing, nurses began to leave the workforce, and nursing school enrollments, which had been declining for a decade, continued to drop. At the time the AONE monograph was written, evidence was just beginning to emerge suggesting that the changes in practice environments were having a deleterious effect on patients and workers alike.

Workforce Demographics

In 2000, experts were beginning to draw attention to the aging of the registered nurse workforce and the implications of this aging for the workforce of the future. Buerhaus, Staiger, and Auerbach (2000) noted that 60% of the RN workforce was over 40 years of age, and the percent of RNs under age 30 had fallen by nearly 40% since 1980. Maes (2000) reported that about half of the RN workforce would reach retirement age within the next 10 to 15 years.

AONE recognized that the aging of the nursing workforce and the nursing shortage was occurring even while the demand for RNs was growing, a fact that was confirmed recently by projections from the Bureau of Labor and Statistics (2004) indicating that the number of jobs for RNs will continue to grow dramatically in the next decade. AONE and others recognize that as patients lived longer, and with multiple chronic conditions, the need for experienced and competent nurses would continue to rise.

Population and Technology

...the need for RNs who could work in faster-paced and increasingly complex work environments became apparent.

Throughout the 1990s, there had been an explosion in technological innovation. New technologies had been developed to diagnose problems, monitor care, and provide medical interventions. Advanced information networks had been introduced, allowing providers to access information across the care continuum and to communicate with one another more efficiently. As the demand for these technologies rose, the need for RNs who could work in faster-paced and increasingly complex work environments became apparent. Health care leaders began to realize that hospitals and other work settings required a higher skill mix of RNs and more baccalaureate-prepared nurses.

When considered together, these factors created a sense of urgency among health care leaders. They led AONE to develop a set of recommendations and strategies to address the nursing shortage and to publish in 2000 the monograph, Perspectives on the Nursing Shortage: A Blueprint for Action.

Recommendations for Resolving the Current and Impending Shortage

The AONE monograph, Perspectives on the Nursing Shortage: A Blueprint for Action (2000) offers a number of recommendations for resolving nursing shortages today and in the future. In particular, it identifies strategies for assessing and anticipating nursing supply and demand, cultivating a skilled workforce; demonstrating the value of nurses within organizations; engaging in initiatives at the federal, state, and local levels; and monitoring progress toward alleviating the current shortage.

Assessing and Anticipating Nursing Supply and Demand

Nursing and other health care leaders, notes the monograph, must urgently focus on the nursing shortage and assure that interventions aimed at abating future shortages are the top priority of every health care, academic, and government institution. The monograph urges collaboration among all stakeholders to ensure a supply of nurses that will be sufficient to meet current and future demand. The plan proposed by AONE relies on mechanisms to stabilize the workforce and interventions aimed at making nursing a more desirable career. Specific strategies include the following:

  • Increasing the supply of nurses (both women and men) by employing dynamic recruitment techniques and providing educational resources and funding to programs that prepare nurses for the increasingly complex work environment
  • Retaining nurses by making changes in the work environment
  • Demonstrating the value of nurses’ contributions to the quality of health care
  • Changing the way nurses are utilized and compensated, thus creating a demand for nurses with varying levels of education and experience

The monograph also makes the case that there is a paucity of national, regional, and organization-specific data addressing workforce planning issues. Data on the following variables are needed:

  • Number of nurses needed to meet basic staffing requirements based on the case-mix and acuity of particular patient populations
  • Variable staffing needs (to accommodate fluctuations in census and changes in acuity)
  • Retirement plans of the current nurse workforce
  • Turnover rate for new nurse hires and factors that contribute to turnover
  • Retention strategies
  • Use of agency nurses (current and projected)
  • Strategies to meet staffing needs when vacancies exceed the capacity to deliver care

Understanding these variables within organizations and across regions will help determine where resources are best placed. For instance, in organizations where the turnover rate of new nurses is high, programs geared toward retention, recognition, and professional development should be a priority. In organizations experiencing difficulty in hiring newly licensed nurses, partnerships with local educational institutions should be nurtured so that creative solutions for recruiting prospective students into nursing can be developed.

Cultivating an Adequate Supply of Nurses and Developing a Skilled Workforce

Since faculty shortages abound, the creation of degree-granting programs that use hospital staff as clinical instructors is an essential strategy for the future.

In addition to the problem with overall RN supply, the AONE report identifies shortfalls within specific specialties, including critical care, emergency departments, oncology, operating rooms, and labor and delivery. A key strategy for addressing both problems is initiating creative partnerships between education and service institutions. Collaborative efforts might include creating and offering specialty education through the Internet and video conferencing, working with local community colleges to create continuing education programs across institutions, developing specialty-specific programs within universities and colleges, and establishing hospital-based internships for newly licensed nurses.

Since faculty shortages abound, the creation of degree-granting programs that use hospital staff as clinical instructors is an essential strategy for the future. Access by practicing nurses to baccalaureate and master’s degree programs must also be a priority for each region. Ample tuition reimbursement programs, online education, paid time for education credits, and making credits available to staff involved in the clinical instruction of nursing students are all strategies that can help to assure a pipeline for emerging faculty.

Demonstrating the Value of Nursing

Compensation models for front line nurses must represent long term financial potential...

The AONE monograph also notes that each organization must systematically demonstrate that nursing’s contributions to the quality of health care are valued. The nursing infrastructure within an institution must be designed to ensure that each nurse leader has a manageable span of control and is positioned within the organizational hierarchy to be a key decision maker. This principle is paramount for the chief nurse executive role and equally important for nurse leaders involved in unit management.

Also noted is the importance of nurses’ involvement in practice and policy decisions, quality improvement efforts, planning for staffing and scheduling, and recognition and retention programs. Compensation models for front line nurses must represent long term financial potential and include mechanisms to recognize clinical excellence, expertise, and commitment to the institution.

Federal, State, and Local Initiatives

The AONE monograph describes a number of strategies that must be undertaken by government agencies and professional associations if the supply of nurses is to meet demand. Increasing funding for the Nursing Education Act, loan assistance programs, and scholarships; expanding Medicare contributions to nursing education; and supporting the ability of foreign trained nurses to obtain visas are just a few of the recommendations offered in the monograph. In addition, the monograph encourages individual citizens to urge state and federal legislatures to support these initiatives and professional associations and health care organizations to lobby in favor of these initiatives.

Monitoring Progress

Patients, families, providers, payers, and policymakers are demanding to know that the diminishing nursing work force is not affecting patient outcomes today. The monograph offers the following recommendations to ensure we are constantly aware of what’s at play:

  • Collect nurse-sensitive data that associates patient outcomes with staffing patterns and care delivery models
  • Collect data about nurse supply, demand, employment, and vacancy patterns
  • Recommend policy changes that facilitate innovation in health care
  • Work with regulatory agencies at the state and federal levels to facilitate communication between providers and patients

These strategies will set the stage for nurse leaders, policy makers, practicing nurses, and interdisciplinary colleagues to create new and evolving practice models that take advantage of emerging technologies, position the professional nurse in the most efficient and productive role possible, and ensure that interdisciplinary care teams are able to meet the needs of the growing number of chronic and complex patients.

Implications for Practicing Nurses

Practicing nurses play a critical role in ensuring that the AONE recommendations, found in Perspectives on the Nursing Shortage: A Blueprint for Action (2000), are put into action. Individual nurses can do much to help shape the work environment of the future and to attract others to the nursing profession. In particular, nurses must become politically active, demonstrate clinical leadership, and be selective when choosing work environments.

Political Action and Professional Association Volunteerism

Nurses can be a potent force in shaping public policy.

Nurses can be a potent force in shaping public policy. Because nurses represent a powerful economic force and influential voting block, elected officials listen to their voices. Nurses, on their own or in concert with professional nursing associations, need to become more politically involved in state and federal government activities and urge legislatures to make necessary changes in funding for nursing education and related programs.

Being active in the American Nurses Association, state associations, and specialty organizations is a critical contribution to improving the nursing shortage. The priorities of these organizations most often include a political action arm as well as a community outreach programs. These activities are essential to continue to promote nursing as a discipline and profession. Supporting these associations financially also allows the groups to conduct research on practice environments, nursing intervention and outcomes, and workforce issues, all of which are critical to the knowledge necessary to assure the growth of the profession.

Community Service and Education of the Public

...participating in health fairs, parish programs, and sports activities will enhance the perception of what nursing contributes...

The roles and positions that nurses may assume are so varied that the general public has only a limited perception of what nurses do. Nurses can serve a role in their own communities to educate the public about what nursing is and to describe the options that present themselves to nurses. Meeting with children in middle schools and high schools to describe nursing as a career, and/or participating in health fairs, parish programs, and sports activities, will enhance the perception of what nursing contributes to the community.

Staying Connected to Nursing Schools

Active involvement in nursing school alumni associations is an important way to support student nurses.

It is also important to consider serving on the clinical faculty of nursing programs.
Additionally, the financial support and personal commitment by alumni allows colleges and universities to demonstrate to potential students, government agencies, and donors, the work of practicing nurses.

It is also important to consider serving on the clinical faculty of nursing programs. This is a wonderful way for nurses to share expertise and knowledge. Health care institutions are now partnering with academic institutions in creative ways. Designating front line staff as clinical faculty is one way to contribute to the burgeoning lack of faculty at the present time. An initiative called "Nurses for a Healthier Tomorrow" ( provides resources for health care organizations partnering with academic institutions to provide interested clinical nurses with the education and support needed to become clinical faculty.

Precepting and Mentoring

Additionally, being an active preceptor and a clinical colleague of newly licensed nurses and newly employed nurses is a rewarding part of professional practice. These activities also serve to promote climates of excellence and lifelong learning in work environments. Creating a milieu of encouragement, acceptance, and support for skill building in the interpersonal, technical, and analytical realm will help these newly employed nurses provide compassionate and expert technical care as they learn in their new practice sites.

Assuming Leadership Roles assuming formal leadership roles...nurses promote nursing as a profession with opportunity for advancement.

Seeking out opportunities to provide formal and informal clinical leadership is one of the most important actions a professional nurse can take to help resolve the nursing shortage. As described earlier, nurses can demonstrate clinical leadership by precepting and mentoring newly licensed nurses, serving as clinical faculty in local academic institutions, and participating on care improvement teams that help define and monitor quality standards and safe practice. Additionally, by assuming formal leadership roles in practice management, advanced practice, professional development, academia, and research, nurses promote nursing as a profession with opportunity for advancement. These leadership responsibilities position nurses to actively change the work environment of the future.

Selecting Work Environments

Finally, nurses must be selective when choosing a work environment. When considering a new employer, a nurse should scrutinize the organization to be sure it espouses respect for nurses and promotes the value of nursing as a discipline. Nurses should ask the following questions: Does the institution employ a practice model that positions the nurse as a key collaborator within a highly functioning interdisciplinary work team? Does it maintain programs that promote ongoing competency and professional development? Does it devote resources to provide evidence-based practice? A positive response to these questions signals that an organization values nurses and nursing practice, and that it is committed to promoting the development of a professional nursing workforce. By avoiding work environments that do not value nursing, nurses may prompt institutions to examine their structures and make changes beneficial to nurses and, ultimately, to the patients for whom they care.

Environments in which nurses and managers share the same expectations about the nursing role and in which nurse’s feel their work and professional development are valued are said to be coherent environments (Reid, Kruger, DeMarco, Hanley, & Conlin, 2004). Coherent environments are marked by a sense of trust between managers and staff and offer a solid foundation for practice development, leadership development, and quality patient care. When selecting a work environment, nurses should examine each institution closely to determine whether it embodies coherence and values nursing practice and the professional development of nurses.


Perspectives on the Nursing Shortage: A Blueprint for Action (2000) provides a plethora of data and detailed strategies that, if enacted, will help address nursing shortages today and in the future. The report encourages leaders in nursing, academia, health care policy, and research to take action to recruit more individuals to the nursing profession, create work environments that promote the professional development of nurses, increase nurse retention, and monitor the status of the nursing workforce on an ongoing basis. It also challenges practicing nurses to seek out leadership opportunities and to play a role in shaping the profession today and in the future. A companion monograph, Nurse Recruitment and Retention Study, (The HSM Group, 2000) identifies novel approaches to recruitment and retention used by nurse leaders around the country. This monograph shares examples of programs and best practices.

Since the publication in 2000 of the AONE monograph, a period of rapid change has ensued, affecting a number of factors that impact the nursing shortage. During this time, the terrorist attack on the World Trade Center occurred on September 11, 2001. In addition, the national and world economies experienced a dramatic decline, creating uncertainty in domestic and world markets and many employment sectors. While segments of the economy have since shown signs of improvement, unemployment remains high in a number of regions and industries. The impact of these changes on the nursing shortage is still being revealed. However, outcomes are predicted to be mixed because economic decline places more stress on the financing of health care, yet high unemployment often leads more individuals to consider nursing as a profession.

During the last few years, health care has also witnessed a backlash to some of the approaches prompted by managed care.

During the last few years, health care has also witnessed a backlash to some of the approaches prompted by managed care.
This backlash began once solid evidence about the deleterious effects of managed care began to emerge and became available to consumers, health care leaders, and the government. The evidence suggested that skimping on resources at the bedside and on resources supporting the competency of practicing nurses has resulted in diminished patient outcomes and disgruntled employees (American Nurses Association, 2001). The Institute of Medicine’s 2001 report, Crossing the Quality Chasm (Committee on Quality of Health Care in America, 2001), mandated a re-visioning of what was necessary to provide safe patient care. Practice environments of respect, interdisciplinary collaboration, and patient and family-centered care were identified as the way of the future. Another hallmark Institute of Medicine Report, Keeping Patients Safe: Transforming the Work of Nurses (Institute of Medicine, 2004) adds significant perspective about the importance of health care working conditions and the effect of these conditions on patient safety.

Other changes since the AONE monograph was published in 2000 include the rebound effect of managed care on the need for increased medical services and a continued increase in patient acuity and in the complexity of technology used to support care. In addition, new evidence about the causes, rates, and effects of medical errors on patient outcomes (Aiken, Clarke, Cheung, Sloane, & Silber, 2003) has underscored the need for a highly skilled nursing workforce and has challenged health care leaders to develop strategies to ensure a high quality workforce for the future.

Since 2000, nursing school enrollment has skyrocketed. Schools were forced to turn away 15,944 students in 2003 due to the shortage of faculty (American Academy of Colleges of Nursing, 2004). The American Organization of Nurse Executives has prioritized faculty development, especially in the area of geriatrics. AONE has also joined the forces of "Nurses for a Healthier Tomorrow" ( to promote tracks to enable clinical nurses to become clinical educators. Additionally, AONE continues to advance the priorities described in the 2000 monograph in areas such as recruiting foreign nurses and a diverse work force, promoting federal legislation to address alternative language to staffing ratios, and encouraging financial support for nursing education.

Most importantly, as suggested by Bleich et al. (2003), AONE is sharing knowledge, collaborating, and forming partnerships with patients, interdisciplinary colleagues, governmental agencies, professional and regulatory associations, national trade and philanthropic organizations, and private-sector industries in order to transcend the nursing shortage and move toward a comprehensive health care system of the future. The solutions to the nursing shortage will come only with a comprehensive and integrated approach in which every nurse serves as a leader, promoting environments of care and compassion for all who need it.


Patricia Reid Ponte, DNSc, RN

Patricia Reid Ponte, DNSc, RN, is the Senior Vice President for Patient Care Services and Chief of Nursing at Dana-Farber Cancer Institute and the Nursing Director of the Hematology/Oncology, Bone Marrow Transplant Program at Brigham and Women’s Hospital in Boston, Massachusetts. She is the Cancer Center nurse leader within Dana-Farber Partners Cancer Care, which includes Dana-Farber Cancer Institute, Brigham and Women’s Hospital, and Massachusetts General Hospital, and is on the board of trustees for the Dana-Farber Children’s Hospital Cancer Center. Dr. Reid Ponte has taught in several local graduate nursing administration programs. She routinely precepts and mentors graduate nursing students and is active in many academic nursing programs promoting partnerships between academia and practice. She received both her Doctorate of Nursing Science and Master of Science from Boston University and received her Bachelor of Science in Nursing from the University of Massachusetts, Amherst. In 1999, she completed the Johnson & Johnson Wharton Fellows Program at the University of Pennsylvania. Dr. Reid Ponte is a Robert Wood Johnson Nurse Executive Fellow, which is a three-year fellowship focusing on leadership development and involving a project on multidisciplinary care teams.

The vision of the American Organization of Nurse Executives (AONE) is to shape the future of health care through innovative nursing leadership and an informed, educated, and participative AONE membership. AONE is committed to ensuring that nurse leaders are poised to create practice environments that capitalize on partnerships with academia, government, interdisciplinary colleagues, and consumers. These work environments and partnerships will assure the vibrant future of a competent, satisfied, diverse nursing workforce.

Dr. Reid Ponte is a member of the AONE publications committee. Her ongoing experience as a chief nurse executive, her active participation in AONE, and her work to promote partnerships between academia and practice settings have provided her with experiences and insights that helped in the preparation of this manuscript.


The author thanks Beth Kantz, RN, and Jane Corrigan Wandel, RN, of Corrigan/Kantz Consulting for contributing to the editing of this article.


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© 2004 Online Journal of Issues in Nursing
Article published May 31, 2004