This article summarizes the major national workforce reports and references the need for a tiered and comprehensive approach to avert the imminent nursing shortage crisis. Since 2002, commendable efforts have been made to increase supply, respond to current demand, and enhance the working environment to benefit recruitment and retention. Four areas are highlighted as exemplars of effort: supply and demand; work environment; new partnerships and public/private ventures; and patient-centered and essential patient-safe care.
Key words: nursing shortage, nurse staffing, strategic planning, workforce, work environment, nurse supply, nurse demand, patient safety, patient-centered care
In April of 2003, the American Journal of Nursing (AJN) published the article, "Analysis of the Nursing Workforce Crisis: A Call to Action" (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. The AJN article lists these reports by stakeholder categories. Several of the most comprehensive documents are summarized in this edition of the Online Journal of Issues in Nursing (OJIN).
When the AJN article was written in 2003, a comprehensive national strategy designed to avert the nursing shortage had yet to be developed. The authors of this current article were then – and continue to be – deeply committed to playing a role in solving the workforce problem. We joined others who recognized that the conditions were right for
The three 'storms' that have combined are an increased demand for nurses, a decreased supply of nurses, and unfavorable work conditions.
This article continues the important dialogue about what is at stake and what the nursing shortage means to the public, the nursing profession, and the delivery systems that served the last several generations of care seekers. In it, an information update and a report of actions taken will be clustered into four discussion categories: supply and demand, work environment, new partnerships and public-private ventures, and patient-centered and essential patient-safe care. Finally, strategies to continue the efforts to resolve work force and work environment issues are offered.
Occasionally problems require solutions that are so interwoven, complex, and dynamic in nature that they defy traditional root cause analysis and action strategies resemble Brownian movement, lacking purposeful direction. The nursing workforce shortage is one such complex problem. In our earlier research a deeper understanding of the problem was gained by using principles derived from meta-synthesis. The themes that described the magnitude of the workforce problem in the narratives and statistics provided by expert stakeholders were "teased out". The problem is best summarized and rooted in:
- inadequate supply of nurses (a diminished "pipeline")
- unprecedented demand for nursing services (with no real capacity to project demand)
- lack of workforce planning (how human capacities and interests are matched with demand in the various practice settings where nurses are needed)
- multiple problems within the work environment (including conflict management and power inequities, inadequate resources, and other issues)
- the paucity of leaders (in number and as prepared for new roles)
- inadequate workforce development (as needed for changing care delivery demands across the health care continuum)
Our analysis showed that projected strategies for action did not map consistently to each dimension of the problem. In many cases, there were no reports of planned actions to resolve an identified dimension(s) of the problem. In one case, actions were in progress (surrounding efforts to capture data and information), but there was no clear linkage from these actions back to a problem dimension.
Our analysis showed that...a defined set of strategies needed development around each problem dimension.
What became clear was that a defined set of strategies needed development around each problem dimension. If strategies could be enacted using a tiered approach, (some being best suited for national-level involvement, like the Nurse Reinvestment Act; others for regional, institutional, and individual actions, like changes to improve nurse recruitment and retention) then the conditions could be sufficiently altered to prevent the cataclysmic outcome that too few acknowledged was plausible. There is growing evidence that this tiered strategy is relevant and helpful in managing the various dimensions of the problem.
The question that needs answering individually and collectively is: "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?"
The Original Reports – Defining the Problem
In reading, coding, and analyzing the 15 national workforce reports, there were many similarities and striking differences noted. One similarity was that multiple stakeholders used three primary sources of data to support their contentions around the workforce shortage. These data were derived from federal agencies, Peter Buerhaus and colleagues, and Linda Aiken and colleagues. Most reports cited demographic
...there is anecdotal evidence that technology currently in use has done little to reduce workload or substitute for human judgment.
...most reports represented only one or two dimensions of the problems...
Another similarity was that most reports represented only one or two dimensions of the problems noted above. That is, stakeholders seemed to limit problem–solution strategies to those for which they had familiarity, or that were best matched for their stakeholder interests. Given the complexity of the problem, this is not surprising, but it has important ramifications in terms of developing a comprehensive approach to solving the workforce problem. Stakeholders are wise to appreciate and support other vantage points and strategies-in-play that reflect approaches different from their own.
...only a few [reports] distinguished themselves by methodically using evidence-based approaches to identify the problem...
Finally, only a few of the reports distinguished themselves by methodically using evidence-based approaches to identify the problem (beyond anecdotal statements) and suggesting plausible strategies for implementation. Many "interventions" were so broad that they failed to give direction, (e.g., "increase the number of nurses" with no directive action statement describing how this could be accomplished), or were vision statements that reflected a "desired state" of what the future might look like. That they were labeled as interventions did not necessarily make them so.
We found it helpful when reading workforce reports to: (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 was a crucial first step in understanding and communicating the problems along with desired solutions.
Update and Actions Underway
Broadly speaking, the changes occurring fall into two sets of activities...promot[ing] recruitment and retention of a qualified workforce...[and] enhancing the work environment.
Since the issuance of these reports, thought-leaders in nursing, medicine, and other health disciplines have given serious attention to the nursing and workforce shortage. Broadly speaking, the changes occurring fall into two sets of activities. One set of activities promotes recruitment and retention of a qualified workforce, while another set addresses enhancing the work environment. Particularly notable are efforts aimed at national policy changes, with voices being heard from health care professional, trade, and labor organizations. Foundations such as the Robert Wood Johnson Foundation (RWJF), the W.K. Kellogg Foundation, the Heritage Foundation, and others are sponsoring demonstration projects with great potential for change. No less remarkable are regional responses to workforce shortages, such as those led by state hospital associations. Local institutional leaders have responded with renewed strength to make the health care work environment a desirable place of employment. Change is taking place.
This next section will report actions that have been taken to date. These actions will be clustered into four discussion categories: supply and demand; work environment; new partnerships and public-private ventures; and patient-centered and essential patient-safe care.
Supply and Demand
Both the American Association of Colleges of Nursing (AACN, 2003a) and the National League for Nursing (NLN, 2003) have reported in their annual surveys a substantial increase in nursing students, reversing a near-decade old downward trend. Particularly notable is the sharp rise in baccalaureate-prepared nurses, with a 21% increase in BSN-graduates reported by the NLN and a 16.6% increase by the AACN. The projection is that some 75,000 new nurses will enter the workforce this year.
Using data from the Current Population Survey conducted by the U.S. Census Bureau, Buerhaus, Staiger, and Auerbach (2003) reported an upsurge of about 100,000 registered nurses in the United
Particularly notable is the sharp rise in baccalaureate-prepared nurses.
In spite of the progress in nurse recruitment, the prognosis for balancing supply with demand is still precarious, at best.
...more than 11,000 qualified students were turned away... due to limited numbers of faculty..., clinical sites, and classroom space.
Further substantiation of this problem is documented in new survey data from the National League for Nursing (NLN, 2003). According to Dr. Lin Jacobson, Director of Research for the NLN, (personal communication, May 5, 2004) the 2002-2003 Survey of RN Nursing Programs revealed that over 30,000 qualified nursing school applicants, across all levels of undergraduate nursing education programs, were either not admitted or placed on waiting lists, at least in some part due to the faculty shortage.
The demand for nurses continues...in acute care, long term care, home care, and public health.
The demand for nurses continues. The U.S. Department of Labor, Bureau of Labor Statistics (2004) cite nurse vacancies based on increased demand in all service areas in acute care, long term care, home care, and public health. Beyond demand, they predict that "thousands of job openings also will result from the need to replace experienced nurses who leave the occupation, especially as the median age of the registered nurse population continues to rise" (U.S. Department of Labor, Job Outlook, para. 1). Nursing is ranked the number one growth occupation of all occupations through 2012.
Although efforts are underway to capture more explicit demand data, models to achieve accurate projections are complex and difficult. The value of knowing the potential demand for services would be useful in planning curricula, projecting service volumes, establishing priorities for health services, and easing the access-to-care burden to those who are under- or uninsured. However, these projections are not yet available. In a period of just one year (2003-2004), the proportion of people who are uninsured rose from 14.6% to 15.2%, impacting 2.4 million people (Association of Academic Health Centers, 2003). The Heritage Foundation predicts that 60 million Americans could be without health insurance by the end of the decade and that at any given two-year time frame, 80 million Americans lack coverage, accounting for middle-class workers opting out of insurance premiums that they cannot afford to pay. Shrinking insurance coverage by employers, racial and ethnic disparities, poverty, and less insurance for middle-class households place increased demands on health systems and providers as this problem escalates (Thrall, 2004).
The full realization of the distressed working conditions faced by nurses has come to light and major changes are underway to improve a situation too often neglected from past downsizing and reengineering initiatives. The American Hospital Association (AHA) and AONE published two volumes of exemplars for creating healthy work environments (Healthy Work Environments: Striving for Excellence, Volume I, 2003; Volume II, 2004). Each volume promotes ‘best practices’ for modifying and enhancing the workplace. Volume II is a research-based compendium documenting six themes that are essential for achieving excellent work environments. These themes are: leadership development and effectiveness, empowered collaborative decision making, work design and service delivery innovation, values-driven organizational culture, recognition and reward systems, and professional growth and accountability.
...the legislative process has also been used to influence change in recent years, particularly in two domains: restricting overtime and mandating staffing ratios.
Voluntary efforts to improve the work environment are robust. But the legislative process has also been used to influence change in recent years, particularly in two domains: restricting overtime and mandating staffing ratios. In 2003, the introduction of the Safe Nursing and Patient Care Act was brought to the House of Representatives, with a companion bill introduced in the Senate, to address nurse burnout and unsafe patient care by restricting mandatory overtime for nurses (American Nurses Association, 2003). More activity has taken place at the state level. Although few states have accomplished legislation to ban mandatory overtime for nurses, there has been increased attention on the issue and some success in gaining legislative mandates (Nelson & Fitzpatrick, 2004; Center for Policy Alternatives, 2004). Similarly, California has passed legislation that requires hospitals to achieve certain patient-nurse ratios to assure quality care and to foster a positive work environment (Jackson, 2004; California Nurses Association, 2003). These strategies, which stir public attention to the working conditions experienced by nurses, are controversial and can be double-edged. For example, mandatory staff to patient ratios might preclude the use of support staff, or might not fully account for patient acuity beyond the prescriptive legislation.
By now, most nurses are aware of the ‘forces of magnetism,’ those attributes associated with distinguished organizations that have created an environment to attract and retain nurses by supporting nursing practice, focusing on professional autonomy, advancing beside decision making, involving nurses in determining the nursing work environment, promoting professional education and career development, and ensuring stable and effective nursing leadership (McClure & Hinshaw, 2002). Achieving Magnet designation by the American Nurses Credentialing Center is a formidable effort requiring hospitals to be both employee- and patient-centered in philosophy and practice. The number of Magnet hospitals is increasing substantially (over 100 hospitals have earned this designation), and the concept is now being promoted in long term care. At long last, organizational leaders acknowledge in a critical mass that improving the work environments for health care providers is considered doing business right.
New Partnerships and Public-Private Ventures
The complexity of workforce and work environment problems has stimulated new partnerships and public-private ventures.
The complexity of workforce and work environment problems has stimulated new partnerships and public-private ventures.
Bringing these elements together is known as Transforming Care at the Bedside (T-CAB). T-CAB will initially focus on redesigned medical/surgical units to achieve outcomes associated with work reliability, patient-centeredness, increased value (including reducing paperwork), and workforce vitality. Already piloted in three hospitals, the next phase of the T-CAB program will include 14 hospitals over a two-year period. The partnership model includes intense feedback loops and target setting around each theme, such as zero unanticipated deaths, and 70% nursing time in direct patient care. No grant monies will be awarded. Participants are model hospitals and national trendsetters with a passion for and a financial commitment to systemic change. The IHI and the RWJF will provide technical assistance over the course of the project (www.qualityhealthcare.org).
Another positive example of public/private partnership is Johnson & Johnson, the U.S. Department of Health and Human Services, and leaders of national nursing organizations. This partnership was aimed at reducing the nursing shortage and elevating the image of nursing. The Johnson & Johnson Campaign was launched in 2002 with astounding results. In April 2003, the first anniversary of The Campaign for Nursing’s Future was celebrated. Additionally, a document entitled Healing the Crisis in Nursing was developed by Johnson & Johnson to report the success of this national campaign (Johnson & Johnson, 2003).
...there is renewed interest among nursing leaders in forming academic-service partnerships.
Finally, there is renewed interest among nursing leaders in forming academic–service partnerships. These partnerships share resources to benefit patient care services and academic preparation of students, stimulating positive changes in curricula and in faculty development and enriching service-based agencies with critical intellectual capital (AACN, 2003b).
Although these partnership exemplars represent great hope, there are still issues of turf, regulatory restrictions on innovation, and a return to strategies that served the past rather than being future focused. As O’Neil (2004) poignantly stated regarding collaboration:
We still spend great effort and resources guarding the towers from the incursions of other professionals or even the public...this is a different day with new patient needs, new types of patients, consumer demands, new technologies and professionals that have a wealth of experience, education, and aspirations (para. 3).
Effective partnerships should help create opportunities for collaboration to shape vision and foster change. O’Neil has challenged us, stating:
There is a serious lack of vision in healthcare today, from the smallest dental practice to the largest multi-campus hospital. We seem incapable of looking beyond how we did it last year, or if we are committed to change it is only on the periphery. We cannot afford such modest dreams... we need health professionals capable of developing and sustaining new visions of what is to come (para. 2).
We conclude that the leadership task of coordinating and focusing a comprehensive plan to resolve the workforce shortage is still amiss of what is needed. We also believe that public-private partnerships bring complementary knowledge, skills, and resources together to examine problems in new and creative ways, making this an important strategy for resolving workforce and work environment issues.
Patient-Centered and Essential Patient-Safe Care
Increased attention is also being given to the culture of error. This attention is supported by linkages that now tie the workforce, workplace, and technology together. The Institute of Medicine (IOM) Report, Keeping Patients Safe: Transforming the Work Environment of Nurses (Page, 2003), examined key elements of the nursing work environment and related these to patient safety.
...the role that nurses play in influencing health outcomes is undeniable...the fatigue factor, unsafe workspace design, fear of reprisal, and inadequate representation on key leadership teams all contribute to diminished patient safety.
The work of many IOM committees is widely known, cited, and addressed in multiple forums. It is their work that is largely credited for the health care industry’s acute awareness of patient safety issues. Yet the need exists for coordination and standardization within the quality movement. Growing in prominence to meet this need is the National Quality Forum (NQF), an emerging player in the health care quality movement.
The NQF was incorporated in 1999 with a mission to "improve American healthcare through endorsement of consensus-based national standards for measurement and public reporting of healthcare performance data that provide meaningful information about whether care is safe, timely, patient-centered, equitable and efficient" (para. 1, www.qualityforum.org/home.htm ). Membership in the NQF includes a diverse coalition that represents all sectors of the health care system, including consumers, vendors, health plans, labor unions, health care providers, and professional organizations. This organization was deemed necessary to find balance between a state-of-the-art health care delivery model and a system fraught with deficiencies in quality. The NQF convened experts to standardize an approach to quality measurement and promote a system-wide approach to improvement. The NQF (as did the IOM committee mentioned above) found error rates as one of three primary indicators of quality deficiencies.
It is interesting that the NQF likened the need for a standardized set of quality measurements to guide systemic change in health care to the work of Florence Nightingale and her utilization of similar strategies to dramatically improve patient care in the Crimean War era. In the NQF report, National Voluntary Consensus Standards for Hospital Care: An Initial Performance Measure Set (2003), the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) charged the Forum with the task of developing core hospital performance measures. After much discourse and intensive work, the group presented 39 nurse-sensitive measures in their initial report. Further measures will be added in time.
The Forum was next challenged to convene a diverse group of stakeholders to encourage widespread use of the approved measures. A national summit was called and resulted in the report, Reaching the Tipping Point: Measuring and Reporting Quality Using the NQF-Endorsed Hospital Measures (2003). Conclusions from the summit underscored the need for immediate action on the recommended strategies if the health care delivery system is going to substantively improve quality.
The Need for Innovation and Continued Focused Efforts
In our AJN report (Bleich et al., 2003) we called, and we again call at this time, for a coordinated and comprehensive plan to resolve the workforce problem and there is growing evidence that planning efforts are occurring and making a difference. Here are two examples, among others, that reflect serious planning efforts.
...there is growing evidence that planning efforts are occurring and making a difference.
The National Nursing Workforce Clearinghouse is another creative example of improved workforce planning, and it can be located at www.nursingclearinghouse.org. This website is an electronic nursing policy resource whose purpose is to provide timely coverage of state and national policy initiatives, innovations in nursing workforce development and health system management, and tools to support professional networking for improvement in nursing. As stated on its introductory webpage, the Clearinghouse used the nursing shortage as a leverage point and that it now will,
...cover issues that have an equally significant influence on nursing workforce and health system management, including public health nursing issues, state legislative decisions, patient safety and quality of care issues, that do not receive adequate coverage through the ‘news’ or ‘policy corner’ features of existing nursing-related websites (n.d., para. 1).
In the introduction to this article, the question was posed,
The three factors (supply, demand, and work environment) that comprise nursing's 'perfect storm' may not materialize with continued surveillance and hard work...
A four-fold strategy is offered below to guide the next phase of our collective efforts:
- Continue to address problems and solutions around supply and demand. Initiatives to improve recruitment and retention strategies must continue unabated. Models to predict demand that are timely, accurate, and regionally useful are imperative and would be an excellent adjunct to complementing supply forecasts. Realize that the storm will hit in 2015, a mere nine years from now! The luxury of time to solve the supply/demand equation does not exist. Academe and service partners must work together in creating an adequate nurse supply, while reacting to actual demand.
- Continue to concentrate attention on improving the work environment. The design and testing of models must more closely resemble real-time work. The development of methods to quick-test models is necessary to promulgate the rapid changes required in today’s workplace settings. Evidence-based approaches that measure the impact of changes in care delivery modes and roles is necessary and leaders must think systemically, so that improving one part of the delivery model does not negatively effect or compromise other parts of the system.
- Continue to pursue innovative, creative, and proactive partnerships to utilize the intellectual and material capital that exists in the private and public sectors. Academe and service can no longer afford to work independent of one another. Efforts to build collaborative relationships, develop critical feedback loops, and foster effective leadership teams capable of innovation and change management must be furthered, not in isolation, but in the broadest terms.
- Continue to overcome barriers that prohibit the elimination of health care quality deficiencies. While patient-centered care is the ideal, there are many situations where the public is not even assured of safe basic care. Nurses must take frontline responsibility for safety-related issues and work diligently with other disciplines and with patients to eliminate the culture of error that is rampant. This must be done rapidly and effectively.
This is a time for personal involvement with policy makers, other providers, and consumers. Each nurse is invited to make a contribution to one or more
This is a time for personal involvement with policy makers, other providers, and consumers.
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.
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.
Article published May 31, 2004
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