How can a health care system effectively function without an adequate supply of front-line caregivers? What are the real reasons for the erosions we’re seeing in the ranks of our nation’s nurses? Is this just another one of nursing’s periodic crises, or does it reflect more serious underlying concerns? And what can we do to reverse the tide of what will become, if left unaddressed, a major public health crisis? These were the questions posed by the Robert Wood Johnson Foundation (RWJF) when it commissioned a study in 2001 to gain a better understanding of the causes of the current nursing shortage in the United States.

The report provided strong evidence that the current nursing shortage sharply differs from those of the past, while noting that previous failures to address underlying issues underscore the current crisis.

As a foundation dedicated to improving the health and health care of all Americans, RWJF embraced the mandate to probe and formulate the operative questions, understand the answers, and seek innovative solutions to match. The resulting report, Health Care’s Human Crisis: The American Nursing Shortage, was published in April 2002 by RWJF to address these perplexing questions and inform the Foundation’s response to the problem. The report provided strong evidence that the current nursing shortage sharply differs from those of the past, while noting that previous failures to address underlying issues underscore the current crisis.

The Foundation wisely realized at the outset that, while it can play a role in shaping solutions, lasting change will require the joint efforts of the many groups that share concern about this problem, such as nurses and nursing leaders, nurse educators, health care industry leaders, labor organizations, policy makers, and the philanthropic community, to name a few. By commissioning the study and publishing the report, RWJF opened the door and invited collaboration among the multitude of organizations that are concerned about this issue to find innovative solutions to this pressing health care problem. In the words of Steve Schroeder, MD, former RWJF CEO and President:

By challenging us to re-examine some of our long-held assumptions about the nursing profession and its position within the health care system, this report lays the groundwork for change. It calls for the health professions and the many groups that have a stake in the issue to break out of their professional silos and work together to realize that change. And it envisions an exciting new future for nursing and the people who depend on its care. (Kimball & O’Neil, 2002, p. ii)

Researchers Bobbi Kimball, RN, MBA, and Edward O’Neil, PhD, MPA., conducted the research for and authored the study in August 2001. It is noted that the report’s contents reflect the views of the authors and not necessarily those of the RWJF.

Summary of the Report Findings

The report (Kimball & O’Neil, 2002) takes a broad look at the underlying factors driving the nursing shortage in the United States. The centerpiece of the report is the introduction of a new model for understanding where various responses to the nursing shortage fall on an evolutionary continuum representing time, complexity, interdependency, professionalism, and care, as defined by consumer needs. By using this new framework to organize the range of activities currently being undertaken by a wide cross-section of organizations, the authors seek to advance actions that address underlying structural issues within the profession and represent long-term sustainable solutions. Much of the following content originally appeared in the report Health Care’s Human Crisis: The American Nursing Shortage. Section titles below match the report’s eight main chapter headings. The full report is available online at www.rwjf.org/news/nursing_report.pdf.

Nursing: A Tradition of Service

Although modern nursing emerged in the nineteenth century, it was the Post World War II explosion of new diagnostic and therapeutic technologies

Nursing's history is rooted in service, but the profession has little autonomy and authority to improve that service.

that resulted in major investments that spurred new hospital construction, health care spending, and a demand for nursing. In response, the profession enlarged educational programs and capacity to enhance the sophistication of its practice and research. However, the model of nursing practice did not change and nursing never gained the independence and authority that the profession of medicine assumed. As the women’s rights movement created more opportunities for all women, the nursing profession became less attractive to women and failed to draw men in large numbers. The advent of managed care and its resulting constraints on hospital resources have made nursing roles increasingly stressful and even less desirable. Nursing’s history is rooted in service, but the profession has little autonomy and authority to improve that service. Until this paradigm changes, the structural shortage of nurses will remain a reality.

A Shifting Environment

A confluence of environmental factors, which are very different from the nursing shortages in the past, may account for the dire predictions over the next two decades. They include:

• An aging population. As 78 million Baby Boomers age, it is highly likely that demand for nursing care will increase and tax the health care system.
• Fewer workers. There are fewer younger people in the general workforce, which has already ignited a "war for talent" in other industries.
• An aging workforce. The physical demands of nursing work serve to limit individuals from working past their mid-50s. With the average age of nurses being 44, a majority will retire in the next ten to fifteen years.
• A mismatch on diversity. The racial and ethnic makeup of the current nursing workforce is not reflective of the increasing cultural diversity of the United States. Recruitment from minority populations must be a priority to address this disparity and attract sufficient numbers of new nurses.
• More options for women. Women have departed nursing for other professions and men have not been attracted to take their place.
• The generation gap. Generation X, the next generation of young workers, perceives nursing as unappealing, highly structured, and stressful.
• Work environment. Inadequate support systems and greater workloads have resulted in dissatisfaction and disillusionment among nurses.
• Consumer activism. Consumer empowerment, increasing awareness of medical errors, and the backlash against managed care have made health care consumers "vigilant participants" in their own care.
• A ballooning health care system. Competition, regulation, and increased pressures in health care financing have resulted in greater demands on a profession lacking the authority to create change within the health care system.

The War for Talent

Other fields that have recently experienced workforce shortages offer useful "lessons learned" to nursing. The corporate world has moved the issue of workforce to the highest level and views workforce as a "strategic asset." Education, military, and religious organizations have employed strategies to attract new talent, from which the nursing profession could borrow. They include:

• Redefining entry to the profession
• Creating career paths that are sustainable with advancement potential
• Focusing on those under represented in the current workforce
• Making these careers attractive to 18- to 25-year-olds
• Providing better recruitment and career information to prospective candidates
• Upgrading the image of their work and professions
• Integrating workforce recruitment and retention strategies
• Creating public understanding of the worker shortage and the will for action

National Reports and Recommendations

During 2000 and 2001, a broad range of stakeholder organizations produced a significant number of reports, white papers, and issue briefs addressing the nursing shortage. Examination of a representative group of these publications identified a series of common themes and recommendations. The common themes of these various publications concurred that this is a different kind of shortage and one that is quantitatively and qualitatively different from past shortages. There was general agreement that past solutions will fall short of the majority of past market-driven solutions and provide only short-term fixes. In the long term, resources will need to be better invested in addressing the underlying issues driving the shortage. Concerns were raised that the public mission is threatened; a shortage of nurses could endanger quality of care and place patients at risk for increased illness and death.

...many of these national reports failed to address the underlying system issues that must be examined and addressed if lasting solutions to the nursing shortage are to be found.

A long-term shortage could undermine the American health care system and emerge as a prominent public health issue. Finally, there is an impending workforce crisis. Work environment issues continue to create formidable recruitment and retention challenges. The demands on nurses have increased, yet work-saving technologies have not been implemented. Simultaneously, new regulations and documentation requirements take nurses away from direct patient care.

Recommendations from the national reports included increasing supply through educational capacity; recruitment and retention efforts; increasing the visibility of nursing contributions to the quality of patient outcomes; increasing compensation and expanding career options; increasing public sector regulatory influence; compiling consistent workforce data for planning; and strengthening nursing leadership at every level. While comprehensive in their recommendations, many of these national reports failed to address the underlying system issues that must be examined and addressed if lasting solutions to the nursing shortage are to be found.

A Range of Stakeholder Strategies

To effectively abate the current nursing shortage, stakeholders will need to work together...for many years to come.

At the time of the study, an abundance of activity to address the issue was already underway on national, state, and local organization levels - evidence that the current nursing shortage has piqued the interest of all sectors of the health care industry and not just the nursing profession. An extensive series of interviews conducted with representatives from key stakeholder groups provided insight to their particular strategies and activities. The major stakeholders and the focus of their efforts are listed below:

National Professional Nursing Organizations

• Working together, respecting expertise, creating unity
• Establishing common goals and objectives in all domains
• Educating lawmakers, shaping legislation, influencing policy
• Improving the professional image of nursing

Health Care Industry and Non-Nursing Professional Organizations

• Uniting efforts across sectors to address workforce challenges
• Enlarging nursing supply
• Educating policy makers, supporting legislation
• Improving work conditions and collaboration among disciplines
• Collecting outcomes data

Labor Organizations

• Strengthening collaborative labor efforts
• Educating lawmakers and supporting legislation
• Influencing compensation and work environment via contract language
• Working toward more "partnership" agreements with employers

Legislatures

• Increasing nursing supply
• Protecting the nursing workforce, improving safety
• Obtaining data for planning

Government Entities

• Administering, monitoring, and regulating as required
• Collecting and tracking information for planning
• Supporting workforce research
• Analyzing and sharing information with key stakeholders

Nursing Education Organizations

• Increasing capacity, recruiting minorities
• Improving educational and training opportunities for nurses
• Expanding the range of teaching technologies
• Enhancing collaboration between education and practice
• Providing qualified faculty

Health Care Delivery Organizations

• Recruitment and retention
• Partnering with schools, communities, and regions
• Improving the work environment
• Developing nursing leadership

Staffing Organizations

• Growing their businesses
• Improving benefits to staff
• Increasing services to their clients

Philanthropic Organizations

• Understanding the underlying challenges
• Identifying potential solutions
• Adding value with focused resources

Each stakeholder group viewed the nursing shortage and its impact on their own mission and goals from their unique vantagepoint. Emerging from the analysis was the realization that no single group could address the critical underlying issues alone. To effectively abate the current nursing shortage, stakeholders will need to work together, in collaboration, for many years to come.

A Comparison of Markets

A comprehensive study of 15 markets throughout the country confirmed that a widespread shortage indeed exists and explored, through focus groups, perspectives of nurses at the bedside. To assess the extent and character of the nursing shortage, the study examined 15 markets across the country with respect to population, economics, health provider characteristics, insurance status, nursing workforce, schools of nursing, and temporary staffing agency demand. Chief nursing officer (CNO) interviews were conducted in each market, and 84 percent of CNOs reported a nursing shortage, with 34 percent of these experiencing vacancies across all sectors of the nursing workforce. CNOs reported that staffing shortages frequently resulted in emergency room diversion, delays in surgeries, or admissions being denied. Strategies being used to offset the nursing shortage in each market included wage and benefit increases, work environment improvements, and changes in care delivery models. The 16 percent of CNOs that reported no shortage at the time of the study cited formalized programs focused on the needs of, and professional recognition for, their nursing staffs as the reason for their adequate staffing.

The number one concern of nurses in all of the groups was their increased daily workload...

Focus groups conducted in 3 markets located in different regions of the country produced findings consistent with other recent surveys from the field. The number one concern of nurses in all of the groups was their increased daily workload, yet they felt relatively powerless to change things they dislike and believed that the image of nursing is poor in large part because of the poor work environment. While most of the nurses planned to stay in nursing, they had concerns that as they age, they will be unable to continue given the heavy workloads and chaotic work environment. Nurses were confused about the financial issues surrounding health care. Nurses saw little commitment from nursing schools and employers to adequately educate, train, and orient new nurses or to offer support for continuing education that fosters professional development. The single positive element was the recognition that nurse managers can make a significant difference in how nurses perceive and embrace their jobs. The nurses made a number of suggestions for addressing the shortage, which can be grouped into the following four broad categories:

• Workload and work environment
• Financial compensation
• Respect and support
• Education and professional development

A Continuum of Responses, An Evolving Profession

Through the introduction of a new model or framework, a new way of looking at the many responses to the nursing shortage is proposed. The compendium of activity that has emerged in response to the nursing workforce shortage spans the entire range from short-term fixes to long-term, future-directed interventions.

Movement along the continuum represents a path by which nursing can progress from being a work force commodity of the health care system to becoming a vital strategic asset, necessary for the success of any health care organization or system.

To sequence the multitude of actions being taken within a framework, envision the current array of activities spanning a continuum. Movement along the continuum represents a path by which nursing can progress from being a work force commodity of the heath care system to becoming a vital strategic asset, necessary for the success of any health care organization or system.

Actions being taken to address nursing workforce are categorized into four stages along a continuum of time, marked by increasing professionalism and complexity. Each stage leads nursing progressively into the realm of a vital strategic asset for the institution or health system served. Underlying themes that enable movement along the continuum include the use of intelligent technology, integration of diversity, and the pivotal role of leadership. The marketplace value represented by the continuum is the emergence of patient services and systems of care that are increasingly defined by consumer needs as opposed to individual or institutional needs. The four stages of response are described as: Scramble, Improve, Reinvent, and Start Over and are illustrated below in Figure 1 (an earlier iteration of this model was originally published in Policy, Politics & Nursing Practice (Kimball & O’Neil, 2001).

There is no intent to judge current actions that fall within the earlier stages of the continuum.

As nurses become more representative of the diversity of the American public, integrate use of intelligent, timesaving technology, and increasingly embrace more autonomy in their practice, their service becomes more responsive to consumers.

In fact, they often represent necessary and evolutionary steps of the profession’s progression. Recalling Abraham Maslow’s historic work on satisfaction and self-actualization, progression is a key element of the need hierarchy (physiological, safety, social, esteem, and self-actualization). As each lower-level need is satisfied, a higher-order need arises as a motivating factor. Using this analogy with respect to the nursing profession, the actions taken in earlier stages (e.g., wage adjustments, safety issues, or scholarships) represent steps that must first be taken in order to forward the action.

In earlier stages, systems of care were generally designed to meet the needs of health care institutions. Thus, as nursing evolves as a profession, it increases in value to consumers. As nurses become more representative of the diversity of the American public, integrate use of intelligent, timesaving technology, and increasingly embrace more autonomy in their practice, their service becomes more responsive to consumers. This evolution is occurring at a point in time when care is progressively defined by the needs of consumers and their families.

Figure 1. (Kimball & O’Neil, 2002) Printed with permission from RWJF

In the Scramble stage, activities focus on nurse recruitment and monetary incentives. The Improve stage is characterized by activities that focus on understanding and meeting nurses needs and wants, such as increasing flexibility, improving the work environment, expanding educational opportunities, increasing diversity, recognizing achievements, and mentoring. In the Reinvent stage, activities focus on professional development and refining nursing practice. These activities may include creating new nursing roles, career ladders, and more professional work environments that integrate autonomy and decision making. In the Start Over stage, nurses practice at the upper limits of their professional licenses and certifications and are viewed as leaders creating entirely new models of care defined by consumer needs. Sustainable progress in addressing the nursing workforce shortage and preventing future shortages will occur when stakeholders grasp the urgency and necessity of initiating and supporting collaborative actions along the later stages of the continuum.

Strategies and Recommendations for Action

As consumers are directly affected by the nursing shortage, they should also be engaged as equal partners in formulating solutions.

The complex nature of the American nursing shortage provides evidence that this shortage is unlike any of those in the past. It calls for bold new solutions and a re-envisioning of the nursing profession itself, so that it can emerge from this crisis stronger and in equal partnership with the profession of medicine. It warns that anything less relegates nursing, and the public that ultimately depends upon its care, to perpetual cycles of shortage and over-supply.

In concluding, the authors recommend that a National Forum to Advance Nursing be created as an independent body, drawing together a wide range of stakeholders to address the nursing shortage and broader, related health and social issues. In an effort to build upon the vast number of activities that are already underway, and to acknowledge their critical value, the Forum would focus on the following strategic areas:

1. Creating new nursing models and entirely new models of health care provision; piloting new ideas that address both the nursing shortage and broader health and social issues; and articulating and advancing the study of nursing’s contribution to patient outcomes and satisfaction
2. Reinventing nursing education and work environments to address the needs and values of, and thereby appeal to, a new generation of nurses
3. Establishing a national nursing workforce measurement and data collection system for strategic planning and comparison
4. Creating a clearinghouse of effective strategies to advance cultural and systemic change within the nursing profession

If past learning serves as a valuable guide, addressing a systemic problem requires the input and support of all those who have a stake in that system. To address the underlying issues driving the nursing shortage and develop meaningful, sustainable solutions will require the active, collaborative participation of all groups that share concern about the nursing shortage. As consumers are directly affected by the nursing shortage, they should also be engaged as equal partners in formulating solutions.

Implications for Nursing Leaders

Whether or not a National Forum for Nursing is eventually created, the immediate implications for every nursing leader in the country are clear. Addressing the intrinsic needs (compensation, orientation and training, safety, workload, scheduling, benefits, support systems, and recognition) of potential and existing members of the nursing workforce is a first step towards reducing attrition and attracting qualified new staff.

Hospitals and health care systems have taken steps to address retention as well as recruitment.

Once basic needs are met, focusing on actions at the higher stages of the continuum of responses (integrating timesaving technology, increasing diversity, creating professional work environments, autonomy of practice, and nursing research) will result in an engaged and motivated nursing workforce. Systematically collecting meaningful data related to nursing workforce (to effectively predict supply and demand) and patient care outcomes (as a direct result of professional nursing care) will enhance the case for investing more resources in nursing. But in the end, creating collaborative partnerships with other stakeholders at the local and regional level to address the underlying drivers of this unique nursing shortage, while designing new models of care and requisite training that reflect the needs of the consumers, will emerge as the sustainable roadmap the profession requires.

Finally, searching out those organizations that are already demonstrating success (i.e., expanding educational capacity and qualified graduates, reducing turnover and vacancies, eliminating use of registry and traveling nurses, and reporting high satisfaction from patients and workforce alike) is necessary to fully understand the level of systemic change and leadership commitment required to sustain a professional workforce in the future. These new approaches have the potential to create new opportunities and alignments for the profession of nursing while designing creative, effective services to ease the coming demand on the health care system.

It is evident that significant progress is being made across the country. National stakeholders, including the American Hospital Association, the Joint Commission on Accreditation for Healthcare Organizations, and the Department of Health Services, have published new reports that underscore the need for action. Federal legislation (the Nurse Reinvestment Act) passed in 2003, but unfortunately was not funded at requested levels. Many states have created Centers of Nursing to collect longitudinal data and address nursing shortage issues unique to their situations. The number of provider organizations seeking Magnet Hospital status has increased substantially. Innovative local partnerships between academic and service organizations have increased the capacity of nursing schools. Local, regional, and national foundations have continued to demonstrate support for nursing workforce initiatives. Hospitals and health care systems have taken steps to address retention as well as recruitment. Labor unions have continued to highlight the issues of work environment in their bargaining and contracting processes.

...the most tangible progress appears to be at the local and regional levels.

Consumers are increasingly aware of the nursing shortage and its potential impact on their care. Certainly more consistent, advanced, and interdependent stakeholder actions are still needed, but at this point in time, the most tangible progress appears to be at the local and regional levels.

Much credit is due to the Robert Wood Johnson Foundation for their invaluable and insightful leadership in creating awareness and encouraging all stakeholders to join together in addressing this critical health care issue. To effectively break from tradition and pave the way to a new future for health care will require multilateral support from all sectors and stakeholders: nursing professional and educational organizations, the health care industry, government, labor, providers of care and consumers. Nurses must lead the way and invite other stakeholders to join forces. It is possible that the American nursing shortage, with its very human face, will emerge as the catalyst to move forward.

Author

Bobbi Kimball, RN, MBA
E-mail:bobbi@kimballassociates.com

Bobbi Kimball, RN, MBA is a health care management consultant and executive coach with 25 years of experience designing, implementing, and promoting innovative change across the health care spectrum. Her professional practice is devoted to assisting organizations and individuals in creatively planning for the future, successfully managing complex change, and enabling transitions that result in growth, empowerment, and healing.

Prior to starting her own business, Ms. Kimball served as a vice president and chief nursing officer at a major tertiary not-for-profit medical center in San Francisco where she was formally recognized as a visionary and advocate for the nursing profession. Her progressive management career includes leadership roles in clinical, educational, research and administrative services that span the continuum of care including acute, tertiary, ambulatory, hospice and a major health plan. Known as an innovative leader and implementer of new consumer-driven services, Ms. Kimball was active in early hospice program development and implemented the first Planetree Model Hospital Unit, a humanistic, patient and family-driven model of health care delivery and patient education.

She currently serves as a Senior Fellow at the Center for the Health Professions at the University of California San Francisco. She also is an advisor to the California Health Care Foundation’s Health Care Leadership Program, the Center for Nursing Advocacy, the California Pacific Health Education Initiative, and, Renew - a nonprofit organization, which assists professionals in re-balancing the competing demands of life.

Ms. Kimball received her Bachelor of Science in Nursing from the University of Florida and a Masters in Business Administration from the University of San Francisco. She holds certifications in executive coaching and facilitation and has additional formal training in fundraising and customer service.

---