Trends in the experiences of hospital-employed registered nurses: results from three national surveys

The comparative results of three national surveys provide the only known source of data describing the evolving state of the nursing workforce over time in this country. These national random sample surveys expose the harmful effects of a lingering shortage of nurses and make plain that much work remains to be done to improve the experiences of hospital-employed RNs. At the same time, nurses and others involved in hospital patient care should be encouraged by the improvements that have been made in recent years, despite the presence of a nursing shortage.     

Six-part series on the state of the RN workforce in the United States

This series on the state of the nursing workforce focuses on describing the results of the national surveys of RNs. The series begins with an analysis of RNs' perceptions of the current nursing shortage and whether they perceive the shortage has gotten better or worse over the past few years. Future topics will include RNs' perceptions of being a nurse and how they perceive certain aspects of their jobs; RNs' awareness of the J&J Campaign and whether they think it has been effective; RNs' perceptions of the impact of the shortage on the quality of patient care in hospitals; and various issues related to the age and diversity of the nursing profession.     

Registered nurses: the impact of wages on labour force participation and hours worked – are wages an effective mechanism for addressing RN shortages with evidence from 1960 to 2008?

Registered nurses (RNs) are critical producers and coordinators of patient care in acute and non-acute settings (Needleman et al. 2011). The Affordable Care Act coupled with an ageing population, are increasing demand for health care and, in turn, RNs. Numbering 3 million, RNs comprise the largest professional occupation in health care. Therefore, the labour force participation and hours worked are of keen interest to stakeholders and policymakers. Rising demand may exacerbate nursing shortages and have important effects on costs. We estimate the impact of wages on participation and hours worked as a possible policy tool to increase nursing supply. In 2008, the RN wage had a positive and significant effect on participation and a small positive but only marginally significant effect on hours worked given participation. The latter elasticity for married females (single females) was 0.11 (0.33). Therefore, the elasticity of hours worked with respect to the nurse wage is and unlikely to have an important effect on the participation rates or hours worked of currently trained female RNs. Consequently, wage increases are unlikely to be an effective policy to increase the labour supply among the currently licensed RNs and will not relieve any short-term nursing shortage.     

The potential imposition of wage controls on nurses: a threat to nurses, patients, and hospitals

When there are shortages of RNs, hospitals and health care organizations in competitive nurse labor markets respond by increasing wages: some hospitals will respond faster and some will offer higher wages than others. The wage increase brings about two important short and long-run outcomes that, together, will increase the supply of RNs in the labor market. Because wage controls prevent the flexibility of wages to adjust, they can cause a shortage to develop when the demand for RNs is increasing (as in the 1970s), and wage controls will lengthen the duration of a shortage once it has begun. The impacts of prolonged RN shortages are multifaceted and destructive to nurses, patients, and hospitals. Looking ahead over the next 15 years when the demand for RNs is expected to grow by roughly 3% per year and the supply of RNs by much less than that, a new nursing shortage is projected to develop and reach a deficit of 285,000 RNs by 2020. The worst thing that could happen to the nursing profession would be to impose wage controls on nurses as this would prevent the needed short and long-run labor supply responses from developing and thereby eliminate the shortage.     

Integrated delivery systems: mergers and acquisitions

Mergers and acquisitions are usually the way an IDS is built. The CNO and/or CNOs/DONs have an integral role in the resolution of the M/A process. During this time of significant change, during which there may even be chaos, the CNOs work to maintain stability so there is as little impact as possible on patient outcomes, a core responsibility of the CNOs. The CNOs should focus on identifying and working with the highly skilled individuals in the organization to get to the recovery stage of the M/A process, at which time a high-performing organization is achieved. To build this new organization or IDS, the old organizations of the M/A must be changed (Moss Kanter, 1994). The successful CNOs will manage the trade-offs and will become experts in collaboration. The CNO's goals are to maximize the quality of patient care, the professional satisfaction of the nurse, and the goals of achieving cost effectiveness for the system (Clifford, 1998), and keeping this focus through the M/A process will yield success.     

Is the shortage of hospital registered nurses getting better or worse? Findings from two recent national surveys of RNs

The results of two recent national surveys of RNs that were conducted at a time when the nursing shortage in the U.S. was in full force (2002) and 2 years later (2004) were compared. The findings provide a mixed assessment: on the one hand, there is evidence that the shortage has eased since 2002 and that there have been notable improvements in the lives of nurses; on the other hand, the shortage has had a negative impact on hospitals and nurses, and longstanding problems associated with the workplace environment remain.     

Awareness and perceptions of the Johnson & Johnson Campaign for Nursing's Future: views from nursing students, RNs, and CNOs

Johnson & Johnson launched the Campaign in February 2002. Data from surveys of nursing students, RNs, and CNOs reflect a high level of awareness of several key elements of the Campaign--advertisements, recruitment materials, the discovernursing.com Web site, and regional "Promise of Nursing" fundraising events. The J & J Campaign for Nursing's Future represents the largest involvement of the private corporate sector, and through this initiative we are learning new and innovative ways to examine the challenges confronting the nursing workforce and develop actions to help resolve them.     

The nursing shortage continues as faculty shortage grows

To combat the nursing shortage, efforts to promote nursing as a career have been successful. However, academic nursing institutions are not adequately prepared for this new influx of applicants. The lack of faculty to educate the growing demand for baccalaureate-prepared RNs directly impacts the nursing shortage. The nursing shortage thus directly impacts safe patient care. The main reasons for the lack of faculty to meet the demand for more nurses include the increased age of the current faculty and the declining number of years left to teach, expected increases in faculty retirements, less compensation for academic teaching than positions in clinical areas for master's-prepared nurses, and finally, not enough master's and doctoral-prepared nurses to fill the needed nurse educator positions It is in the best interest of the nursing profession to do what it does best by incorporating the nursing process to solve the faculty shortage and secure its future in order to protect the lives of patients.     

Health care reform: current updates and future initiatives for ambulatory care nursing

While the signing of the Patient Protection and Affordable Care Act was a historical event marking the beginning of health care reform in the United States, it signaled the start of a golden age for ambulatory care nursing. Ambulatory care RNs are well-positioned to fully participate in health care reform initiatives. RNs are well-positioned to lead, facilitate, and/or participate in all patient care medical homes' and accountable care organizations' quality and safety initiatives through enhanced use of major ambulatory care RN role dimensions such as advocacy, telehealth, patient education, care coordination and transitional care, and community outreach. RNs are also well-positioned to provide patient-centered care, coordinate care, and manage transitions across ambulatory care settings. For the golden age of ambulatory care nursing to become a reality, initiatives surrounding competencies, education modules, and leadership must be addressed immediately.     

Nursing leadership: championing quality and patient safety in the boardroom

OBJECTIVE: Identify the extent to which hospital boards of trustees, CEOs, and CNOs are engaged in quality and safety at the leadership and governance level and how CNOs can support board engagement in quality and safety. BACKGROUND: Although research is emerging, still relatively little is known about the impact and interface of hospital boards of trustees, CEOs, and nursing executives related to improving quality and patient safety. METHODS: 73 telephone interviews were conducted with hospital board chairs, CEOs, and CNOs from a convenience sample of 63 U.S. hospitals. The interviews (22 of which were with CNOs) lasted 30 to 45 minutes and were supplemented by a focus group of five nursing executives. RESULTS: There are significant differences in the perceptions of CNOs versus those of board chairs and CEOs. CNOs reported a greater familiarity of landmark reports on quality and patient safety than board chairs. CEOs and board chairs gave substantially higher ratings to integration of quality planning. Boards have limited comprehension of salient nursing quality issues. CONCLUSION: CNOs have a critical role as boardroom champions of patient safety and quality improvement.     

The impact of nurse staffing on hospital costs and patient length of stay: a systematic review

Research examining the relationships between nurse staffing, hospital costs, and length of stay is varied using a range of methods and definitions. This lack of coherence in definitions and measurement tools for cost and length of stay makes it difficult to conclude with certainty the results of nurse staffing on hospital cost and length of stay. However, the evidence reflected that significant reductions in cost and length of stay may be possible with higher ratios of nursing personnel in hospital settings. Sufficient numbers of RNs may prevent patient adverse events that cause patients to stay longer than necessary. Patient costs were also reduced with greater RN staffing as RNs have higher knowledge and skill levels to provide more effective nursing care as well as reduce patient resource consumption. Hospital administrators are encouraged to use higher ratios of RNs to non-licensed personnel to achieve their objectives of quality patient outcomes and cost containment.     

American Academy of Ambulatory Care Nursing position statement: the role of the registered nurse in ambulatory care

Ambulatory care nurses are leaders in their practice settings and across the continuum of care. They are uniquely qualified to influence organizational standards related to patient safety and care delivery in the ambulatory care setting. The current ambulatory care setting is diverse and multifaceted, requiring nurses highly skilled in patient assessment and with the ability to implement a broad range of nursing interventions in a variety of settings. The future of the American health care system depends upon our ability to utilize RNs to the fullest extent of their expertise, licensure, and certification.     

Redesigning nursing work in long-term care environments

The authors present a highly statistically oriented argument for examining work attitudes and activities among three groups of caregivers [RNs, RPNs, and HCAs] working in long-term care. The investigators used both work sampling, written surveys, and interviews with a sample of 46 caregivers in a large university-affiliated LTC facility in Toronto, Canada. While RNs stated their strong affinity for direct patient care activities, they perform the lowest percentage of direct care, chiefly due to their accountability for planning and coordinating the care provided by others. The HCAs who provided the bulk of direct patient care "valued it the least," apparently finding little gratification with this aspect of their role. This study suggests that there is a need to examine and clarify work roles and perceptions for all caregivers as part of any work redesign process. A higher level of RN involvement in direct patient care activities, along with "attention to enhancing the importance" of these activities for staff employed in the HCA role, could be beneficial.     

The use of unlicensed assistive personnel and selected outcome indications

This pilot study examine the satisfaction levels of patients, RNs, and UAPs after implementing a patient care delivery system using UAPs as nurse extenders on a 41-bed short-stay medical-surgical observation unit. It also compared patient fall statistics prior to and after implementing the new care model. The convenience study sample included 40 patients, 15 RNs, and 9 UAPs and covered 2 months of unit experience in mid 1997. Risk management statistics from a comparable period 2 years prior showed no significant difference in the number of patient falls. Patient satisfaction scores on five of the seven regularly collected questions was higher in 1997 than the comparable earlier period. RN satisfaction with the care model using UAPs was above a neutral score of 3 on a 5-point Likert scale on two out of three items, but additional attention to the RN's role in effective delegation to UAPs was needed.     

California regional registered nurse workforce forecast

OBJECTIVE: To forecast the shortage of registered nurses (RNs) of the 24 Primary Metropolitan Statistical Areas (PMSA) and Metropolitan Statistical Areas (MSA) in California. BACKGROUND: A nursing shortage prevails nationally and is most serious in the state of California. Successful interventions in the alleviation of the RN shortage will require effective resource allocation and academic program development in various regions throughout the state. While various published studies have focused on nursing workforce development at the state and even regional levels, there are no studies focused on identifying RN shortages at the PMSA or MSA (P/MSA) level. In this report, a forecasting model is developed to systematically analyze the future supply and demand of the RN workforce within each California P/MSA. METHODS: Using accessible public databases, forecasting models were constructed to project the demand and supply of RN jobs in California P/MSAs. In the demand model, population age and size were used as determinants of regionally required RN jobs. In the RN jobs (supply) model, a region's supply of RNs was the net sum of factors increasing and decreasing the regional presence of RN jobs, including RN graduations, migration, and aging of the RN workforce. The combination of these supply and demand models was used to produce regional RN shortage forecasts for future years. RESULTS: Almost all regions exhibited growing shortages by 2020 at rates ranging from 3% to 600%. Using a modified version of the grading rubric of the California Regional Registered Nurse Workforce Report Card (Lin, Lee, Juraschek, & Jones, 2006), only two regions will receive a grade above "C" in 2020. The number of "F" grades will grow to nine. CONCLUSIONS: California has the lowest RN ratio in the United States (Fletcher, Guzley, Barnhill, & Philhour, 2004; Health Resources and Services Administration, 2004a) and this RN workforce forecasting model shows that over the next 15 years, the majority of P/MSAs in California will have increasing RN shortages. This analysis has significant policy implications including the need to create specific plans to mitigate the effect of the California shortage.     

Hospital staff shortage: the role of the competitiveness of pay of different groups of nursing staff on staff shortage

Shortages of nursing staff in OECD countries have been a preoccupation for policy makers. Shortages of staff may be the consequence of uncompetitive pay. In the private sector, employers in different regions can offer different pay rates to reflect local amenities and cost of living. Hospitals in the UK however cannot set the pay for their employees, and as a result they might therefore incur staff shortages. Moreover, occupational groups do not operate in isolation. Shortages of staff may also be the consequence of the competitiveness of pay of an alternative group of staff. This is investigated using two distinct groups of nursing staff: assistant nurses (ANs) and registered nurses (RNs) working in English hospitals in 2003–2005 using national-level data sets. We find that an increase by 10% of the pay competitiveness of RNs decreases the shortage of both the RNs and of ANs by 0.6% and 0.4%, respectively.     

Characteristics of internationally educated nurses in the United States

Among an estimated 2.7 million U.S. nurse workforce in March 2000, about 4% were internationally educated nurses. This secondary analysis of the 2000 National Sample Survey of Registered Nurses profiles this unique segment of the U.S. nurse workforce. Findings indicate that internationally educated nurses have distinctive demographical, educational, and employment characteristics when compared to U.S.-trained nurses. Implications of the findings are elaborated in lieu of the present U.S. nurse shortage.     

Evolution of the chronic care role of the registered nurse in primary care

High-quality, accessible, and efficient primary care is needed as the U.S. health care system undergoes significant change. Advancing the role of registered nurses in the primary care setting is important to the solution. A large academic health center implemented five initiatives to improve the care of chronically ill patients through the expanded role of RNs in the context of the health care team. Role evolution of nurses in the pilots required some continuing education and some additional nursing support to release the pilot nurses from their usual duties. These strategies allowed the nurses to apply interventions that enhanced the coordination of care and promoted patient self-management skills. Some short-term improvements in health status were realized and barriers to self-care were identified and resolved.     

Validating HRSA's nurse supply and demand models: a state-level perspective

In addition to federal initiatives, solutions to the nursing shortage must also be devised at the state level. Understanding the timing and severity of the nursing shortage in a particular state is paramount to devising appropriate solutions In 2005, the Health Resources and Services Administration released new versions of the Nurse Supply Model and Nurse Demand Model designed to project the supply of RNs and demand for RNs, LPNs, and nurse aides in the United States through the year 2020. The process used by two state-level analysts to project nurse supply and demand in North Carolina using the HRSA models is described. The authors conclude that the models work well for state-level forecasting but that users should carefully assess the default data provided with the model against independent data sources specific to their states.     

Why are shortages of hospital RNs concentrated in specialty care units?

This article is the first in a series examining the interplay between the aging of the nurse workforce and other factors driving the growing nursing shortage that are already affecting some specialty areas. Nearly 60% of the current RN workforce is over 40 years of age; and the percentage of RNs under age 30 has fallen by nearly 40% since 1980. The total number of FTE RNs is projected to shrink after 2010, likely resulting in shortages of RNs "when the large baby-boom generation of RNs starts to retire." Because ICUs have historically attracted younger RNs, the rapid decline in the number of RNs in the workforce under age 30 plays a large role in explaining the development of shortages in the ICU. The growing difficulties staffing operating rooms and other peri-operative services is seen as related to the aging work force as more diploma prepared nurses have been attracted to this specialty because they had educational exposure to this area.