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Overview: The Endangered Health System: A Progress Report on Workforce and Work Environment Issues

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Peggy O. Hewlett, PhD, RN
Michael R. Bleich, PhD, RN, CNAA-BC

Citation: Hewlett, P., Bleich, M., (May 31, 2004). "Overview and Summary: The Endangered Health System: A Progress Report on Workforce and Work Environment Issues". Online Journal of Issues in Nursing. Vol 9 No 2, Overview and Summary.

DOI: 10.3912/OJIN.Vol9No02ManOS

In April of 2003, the American Journal of Nursing published our analysis of the nursing workforce crisis (Bleich, Hewlett, Santos, Rice, Cox, & Richmeier, 2003). This analysis was culled from 15 public documents issued during or prior to 2002 and reflected various stakeholder perspectives with a national view of the nursing workforce crisis. At that time, we stated that a comprehensive national strategy designed to avert the nursing shortage had yet to be developed. As two individuals deeply committed to playing a role in solving this workforce problem, we joined others who recognized that the conditions were right for a ‘Perfect Storm,’ a powerful metaphor for what was unfolding.

This OJIN topic features summaries of three of the original 15 national reports included in our analysis. Additionally, OJIN has included our manuscript, Dissipating the ‘Perfect Storm’: Responses from Nursing and the Health Care Industry to Protect the Public’s Health. This article continues the important dialogue about what is at stake in this nursing workforce crisis and what the crisis means to the public, our profession, and the delivery systems that served the last several generations of care seekers.

Reports of Note

The three reports summarized for readers of this OJIN topic are examples of reports that made strong descriptive cases to holistically and comprehensively describe the nature of the workforce problem. Each report thoughtfully presents strategies to resolve the workforce issue. For those unfamiliar with these documents, the synopses provided will be useful. For those who are familiar with them, it is a useful exercise to reflect on the progress, and challenges, that remain.

Kimball reports on her work with O’Neil, entitled Health Care’s Human Crisis: The American Nursing Shortage (2002), and funded and published by the Robert Wood Johnson Foundation ( Kimball and O’Neil capture the essence of nursing in a historical context and aptly describe the environmental factors that account for the magnitude of the workforce problem. A compelling strength of this article is graphically portrayed as the "Continuum of Responses to the Nursing Shortage." This graphic, unlike any other in reports we reviewed, reflects and projects the transformation of and redefinition of the nursing discipline from the mental model of nursing as a commodity to nursing as a professional partner. It also projects the public consequences of non-transformation. Every nurse, healthcare provider, and consumer should be exposed to this work.

Reid Ponte summarizes the monograph of the American Organization of Nurse Executives (AONE), one of the first major papers issued on the workforce issue, titled, Perspectives on the Nursing Shortage: A Blueprint for Action (2000). This article is easy to appreciate as a backdrop for understanding the nature of the workforce issue. The AONE report makes a significant contribution by emphasizing the importance of data to inform workforce planning and describes the characteristics of the work environment needed to support recruitment and retention of nurses, linking nursing to organizational success. While it is hospital focused, this report serves as an example of one that reflects its constituency, yet still offers a perspective beyond the organization’s self interest. In it, a strong case is made for developing a skilled workforce to interact with the high technology environments that hospitals have become and are becoming.

The American Nurses Association (ANA) report, Nursing’s Agenda for the Future: A Call to the Nation (2002), is summarized by Kany ( The ANA report reflects the perspectives of multiple work groups who collaborated to create a plan to resolve the problem by envisioning a desirable future. As participants described a desired future state for the nursing discipline, strategies and partnerships that might influence constructive development and evolution of nursing to meet the public’s needs were documented.

Finally, in mapping the impending storm, we point the reader to two other significant and noteworthy documents not currently summarized in this OJIN topic. The American Hospital Association (AHA), through a Commission on Workforce for Hospitals and Health Systems, issued the report In Our Hands: How Hospital Leaders Can Build a Thriving Workforce (2002). Also issued that year was the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO, 2002) report, Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis. Both contain comprehensive views of the workforce and work environment issues that confound the problem, and both are substantive in their presentation.

When reviewing all of the aforementioned reports: (a) recall the stakeholder writing the document, (b) look for similarities and differences in descriptions of the problem and solutions being recommended, and (c) reflect on the work that remains to protect the public’s interest. Being informed is a crucial first step in understanding and communicating the problems – along with desired solutions.

In our article we note for the reader some of the substantial efforts and exemplars that have come about since 2002 in the nation’s effort to tackle the ongoing nursing shortage and its impact on the public’s health. This is the question each of us needs to address: "Has the momentum gained, and are the efforts undertaken enough to dissipate the intensity of the storm scheduled to reach full strength in 2015 and beyond?"


Peggy O. Hewlett, PhD, RN

Peggy O’Neill Hewlett has over 25 years experience in nursing education, administration, practice, and consultation. Currently she serves as Professor of Nursing and Associate Dean for Research and directs the Doctoral Program at the University of Mississippi Medical Center (UMC) School of Nursing in Jackson. She earned BSN and MSN degrees from the Medical College of Georgia, and a PhD in higher education and leadership from the University of Mississippi.

Prior to her work at UMC, Dr. Hewlett was project director for the Mississippi Office of Nursing Workforce, a Robert Wood Johnson Foundation Colleagues in Caring grant initiative. Under her leadership, outcomes of the program included a workforce development model to forecast statewide workforce needs, an integrated nursing competency-based educational mobility plan, a statewide health care career counseling program, and the initial development of an interdisciplinary Healthcare Leadership Institute.

In 2000, Dr. Hewlett was selected for the Robert Wood Johnson Executive Nurse Fellows Program. Her leadership project included initiatives to establish the Center for Building Healthy Communities at UMC, to enable community-based projects with strong assessments, research designs, and evidence-based outcome measurements, and to facilitate model development for rural primary health care delivery with representatives from nursing, medicine, dentistry, and allied health.

Dr. Hewlett recently was a co-principal investigator in an analysis of the major national reports describing nursing workforce shortages. She is a speaker and scholar for a broad spectrum of nursing workforce issues and is an inaugural member of the newly established National Nursing Workforce Clearinghouse Advisory Board at the University of California San Francisco Center for the Health Professions. Her research led to the development of a framework being used at UCSF to coordinate comprehensive solutions to workforce problems through innovative national, state, and local academic/service partnerships.

Michael R. Bleich, PhD, RN, CNAA-BC

Michael Bleich brings over 30 years of experience to his work in health care education, administration, and consultation. Bleich received a diploma in nursing from St. Luke’s Hospital School of Nursing, a baccalaureate degree in nursing and liberal arts from Milton College, a master’s degree in Public Health (Patient Care Administration) from the University of Minnesota, and a PhD in Human Resource Development from the University of Nebraska-Lincoln.

Dr. Bleich currently is the Associate Dean of Clinical and Community Affairs at the University of Kansas School of Nursing. He is also the Executive Director and Chief Operating Officer of the School’s nursing corporation, KU HealthPartners, Inc. His diversified experience includes executive-level management in hospitals, national and international consulting, and academic appointments in nursing and health services administration.

Areas of management expertise include academic clinical enterprise operations, clinical systems design, work analysis and reward systems development, quality improvement and outcomes measurement, leadership coaching, and regulatory standards interpretation and analysis. Bleich has authored multiple articles, book chapters, and monographs, as well as serving as a reviewer and/or editorial board member for several journals.

Dr. Bleich was named a Fellow in the Robert Wood Johnson Executive Nurse Fellowship Program for 2000 – 2003 and was a 1996 Fellow in the Johnson & Johnson/Wharton School of Business at the University of Pennsylvania nurse executive program. In 2003, Dr. Bleich was appointed to the National Advisory Committee for Nursing under the sponsorship of JCAHO. He holds memberships in the American Organization of Nurse Executives, the American Nurses’ Association, and Sigma Theta Tau International.


American Nurses Association. (2002). Nursing’s agenda for the future: A call to the nation. Available:

American Organization of Nurse Executives Monograph Series. (2000). Perspectives on the nursing shortage: A blueprint for action. Chicago, IL: American Organization of Nurse Executives.

Bleich, M.R., Hewlett, P.O., Santos, S.R., Rice, R.B., Cox, K.S., & Richmeier, S. (2003). Analysis of the nursing workforce crisis: A call to action. American Journal of Nursing, 103(4), 66 – 74. Retrieved May 5, 2004 from the world wide web at:

Commission on Workforce for Hospitals and Health Systems, American Hospital Association. (2002). In our hands: How hospital leaders can build a thriving workforce. Available at:

Joint Commission on Accreditation of Healthcare Organizations. (2002). Health care at the crossroads: Strategies for addressing the evolving nursing crisis. Available:

Kimball, B., & O’Neil, E. (2002). Health care’s human crisis: The American nursing shortage. Princeton, NJ: The Robert Wood Johnson Foundation.

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