In our integrative review of reports on the health care workforce shortage, we examined 15 reports that focused primarily on nursing and were conducted by various stakeholders. We studied these reports objectively, identifying problems and solutions as described by the authors, which we then categorized by theme. We found problems at both the national and institutional levels and noted that the reports contained similar problem and solution "themes." Yet we also found gaps between these-some problems had no solutions and some solutions didn't address any of the suggested problems. Gaps occurred among problems and solutions listed in the following theme categories: demand, health care economics, workforce planning, research and data support, and technology.

We present the results of our analysis and our recommendations to the federal government and national organizations, to institutions, and to nurses. These recommendations don't provide a comprehensive strategy for averting the nursing shortage, but they do offer a basis upon which one may be created.

Like forecasters interrupting television programming to warn of impending storms, national organizations, philanthropic foundations, labor and economics specialists, and the federal government have issued reports on the shortage of health care workers in recent years. Many focus on the nursing shortage; each predicts imminent workforce shortages. But the reports differ in style and substance and in strategies for averting the worsening of the shortage in the next two decades.

No neutral body has examined these reports collectively and then synthesized the content to determine broader strategies and recommendations.

OBJECTIVES

We sought to conduct such an analysis. We considered our research group to be neutral because we adhered to an appropriate methodology for conducting such a review without bias or regard for any one report. Our goals were to objectively examine some of the reports that focused primarily on the nursing shortage, to analyze and categorize the data they contained, and to offer to the federal government, national organizations, institutions, and nurses a number of recommendations upon which a comprehensive national strategy to avert the nursing shortage could be based.

We addressed the following questions:

* What types of data were used to substantiate the health care workforce crisis?

* Were the same data used in different reports?

* What descriptive themes expressed the scope and intensity of the workforce problem (that is, those factors that contribute to the shortage)?

* To what extent did the solutions address the problems?

We initially reviewed some 35 reports, but only 15 met our criteria and were included in our review. Some had been issued as formal documents (such as special reports to a constituency), others as journal articles, and still others as reports from consultants; many had been released both in print and online (see The Reports Studied, page 70). They were created for various constituencies in diverse practice settings.

Our results are organized around the research questions.

What types of data were used to substantiate the health care workforce crisis?

Because of multiple stakeholders' reliance on data to educate their constituents on the workforce problem, we analyzed the primary sources of the data, which included coding the data by type and reviewing the consistency of data findings across reports. (A wide variation in data type or inconsistent data citations might lead to concerns about the legitimacy of the problem.) Quantitative data in the reports we examined were used by the authors to substantiate the shortage. Twelve of the 15 reports relied on at least one of the following three types of data to substantiate the escalating shortage:

* demographic data, which were used to specify projected population shifts, thus depicting the demand for additional health care workers

* current and projected "supply data," which described how many RNs were available and how many would be needed in the future

* data on nurses' satisfaction with their own work environments

The abundance of work environment and nurse satisfaction data in the reports surprised us, since we expected more emphasis on supply and demand. We surmise that the authors assumed that stakeholders had knowledge of supply-and-demand data because of its wide acceptance. The reports focusing on the work environment most often cited specific nursing concerns, such as nurses' willingness to remain in the profession, or their concerns about patient-nurse ratios.

Were the same data used in different reports?

The reports derived most of their data from three primary sources, which we found to be credible, valid, and reliable:

* data from various federal agencies (used in 11 of the 15 reports)

* several studies by Peter Buerhaus and colleagues (two of the reports were based entirely on their research, and their work was cited in five other reports)

* several studies generated by Linda Aiken's research team (cited extensively in three reports, particularly in regard to patient clinical outcomes associated with staffing)

One notable exception involved the projected scope of the shortage. The reports we studied predicted a shortfall ranging from 400,000 to 1.5 million nurses by 2020.

What descriptive themes expressed the scope and intensity of the workforce problem?

To identify common themes associated with the workforce problem, we coded the text of each report and began to cluster this information under labels derived in the research analysis (see Descriptive Themes and Subthemes of the Workforce Shortage, page 71). To be included as a "primary theme," text related to the theme had to be noted in at least five of the 15 reports; to be classified a "subtheme," text related to the theme had to appear in at least three of the five reports. For example, at least five reports described health care economics as a factor in the workforce problem, and at least three of these reports were more specific and discussed "cost of labor" as part of health care economics, making it a subtheme.

By restricting the findings to major themes and subthemes, isolated problem statements present in fewer than five reports-which may have validity but could also represent a stakeholder's bias-were eliminated. Through the clustering of themes, a "big picture" view of the most critical issues and substantive solution recommendations could be determined.

In Descriptive Themes and Subthemes of the Workforce Shortage, page 71, we describe the themes we identified, provide information on their prevalence in the reports, and label the themes as either "national" or "institutional" in scope. Our results show that the health care workforce shortage is more complex than a simple imbalance in supply and demand. The following statements from two of the reports illustrate how text supports the themes, such as those found under the health care economics theme:

To what extent did the solutions address the problems?

After noting the problems in these reports, we grouped the proposed solutions by theme, employing the same coding procedures as above. Most of the reports were not designed as solutions but rather described or clarified the scope of the shortage. But four reports-those issued by the Joint Commission on Accreditation of Healthcare Organizations, the Robert Wood Johnson Foundation (authored by Kimball and O'Neil), the American Hospital Association, and the American Organization of Nurse Executives-identified problems and offered corresponding solution strategies. "Nursing's Agenda for the Future" differed from the others in that it consisted of a series of visioning exercises that enabled the authors to identify a variety of ways to improve the shortage. These improvements were categorized into 10 domains, such as "Public Relations-Communications." The report also identified which stakeholders could work toward improving each domain.

We analyzed whether proposed solutions adequately addressed the identified problems. If an identified problem had no potential solution, or if a suggested solution didn't appear to address any of the stated problems, we determined there was a "gap" between the problem and solution and surmised that additional strategies were needed. Gap Analysis of Workforce Problem-Solution Themes, on page 73, lists the problem and solution themes and shows any gaps between the two. Our findings, which we termed a "gap analysis," identified three problems that had no suggested solutions and two solutions that did not address any of the problems presented in the reports.

Problems without solutions.

Although we discovered that demand was identified as a problem in several reports, none of the solution themes we identified addressed population and demographic trends, including the aging of the population. Moreover, under the economic problem theme, we found no solution themes that addressed the high cost of nursing labor relative to the number of nurses working as part of the total health care workforce, or nurses' perceptions of their salaries as inadequate or compressed. Further, no solution theme addressed the need for economic policies that could ensure fair reimbursement of nursing services across the health care continuum or other related policies with economic implications, such as access to care.

Sufficient solutions to ensure an adequate workforce were also lacking. Based on the text that described this problem theme, we could infer that strategies should promote intraorganizational planning (for example, coordinating efforts between local hospitals and schools of nursing to ensure supply and demand). In another instance, we inferred that regulatory and professional associations could collaborate at the regional or national levels-on intense recruitment efforts, for example-to optimize resources to solve the shortage problems. It's likely that health policy changes will be needed to help support these solutions, although the authors of these reports did not make recommendations regarding either the type of changes needed or who would make these changes.

Another problem theme was workforce development, such as the nursing educator's ability to ensure that basic and advanced nursing education enables nurses to meet patients' care needs in a variety of settings, including public health. The pace and intensity of nursing work are described in the reports and indicate that a problem exists in keeping staff abreast of clinical and organizational changes. Therefore, the need for continuing education becomes part of the workforce problem. As stated above, the reports imply that solutions are needed to reconcile the tension between education and practice realities, and that nurses must embrace lifelong learning. The reports also highlight the need for preparing and expanding the public health workforce to address emerging issues, such as bioterrorism, which could dramatically affect the public's health.

Solutions without problems.

Conversely, there were solution themes that emerged in five or more reports during the analysis that were not directly tied to any problem theme. Those most frequently cited relate to the significance of data as a measure of determining, first, whether the workforce problem is improving or not and, second, whether improvement can be measured in the remedies that are being implemented. For instance, researchers would need to gather data at the institutional level to determine whether nurses were satisfied with a new staffing model or a new technology introduced to alleviate manual work. In addition, such data would be needed to measure the effectiveness of a demonstration project that introduced an innovative care model aimed at improving patient and staff satisfaction. Similarly, regional or national data are needed if researchers wish to survey the effects of regional or national nurse recruitment efforts or study the overall supply-and-demand balance. Although there was no explicit statement regarding the absence of sufficient data as part of the workforce problem, these examples implicitly suggest that there are inadequate data to examine supply and demand, new programs, and patient and staff satisfaction.

Technologic solutions were envisioned in which the nurse's workload is streamlined to enhance productivity and decrease the time spent charting, yet these solutions didn't address any of the problem themes stated in the reports. Three reports offered technologic solutions that would shift nursing work away from certain tasks.

The reports we studied provide various perspectives on the scope of the nursing shortage. To a lesser degree, they also offer strategies for averting a national public health crisis. Yet the complexity of the shortage makes it difficult for any one entity to explain it fully.

All of the reports we examined acknowledged the shortage, but the specificity of the recommendations for resolving it varied greatly. For example, four of the 15 reports-issued or authored by the American Hospital Association, the Joint Commission, Kimball and O'Neil, and the American Organization of Nurse Executives-provided specific action plans. Three others-from the American Association of Colleges of Nursing, Gelinas and Bohlen, and Needleman and colleagues-implied but didn't categorically suggest strategies. "Nursing's Agenda for the Future" and reports from Joseph and Melick, Hart (2001), the Service Employees Union, and the U.S. Department of Health and Human Services contained broad recommendations or suggestions that didn't specify who should implement the changes. The remaining documents contained opinions or views that were not written with the aim of specifying potential solutions to workforce problems. Thus, despite the need, a comprehensive and coordinated national strategy designed to forestall the nursing shortage has yet to be created.

Our research provides a broader perspective from which to understand the workforce problem. The gap analysis clearly shows a lack of comprehensive solutions to the problems. We also discovered that the scope of the problem is still being defined, as evidenced by the fact that some strategies for action do not correspond with the described problems.

We believe that a comprehensive workforce plan can be built upon our gap analysis and should include

* clear problem statements (related to each theme noted in Descriptive Themes and Subthemes of the Workforce Shortage, page 71).

* agreement over desired outcomes (based on the seven imperatives described below).

* focused, tiered strategies (on the national, institutional, and individual [nurse] levels) to achieve these goals.

Although the nursing shortage currently varies by region-and it will continue to-it's a national problem that merits a collaborative solution by the federal government; national trade, professional, and regulatory associations; philanthropic organizations; and private-sector industries. We found three national-level imperatives emanating from the 15 reports.

* Economic imperative; sample strategies:

[black vertical rectangle] Develop public policies favoring fair reimbursement for basic and advanced nursing services.

[black vertical rectangle] Consider allocating a portion of federal health care reimbursement dollars to workforce planning and development.

* Workforce planning and development imperative; sample strategies:

[black vertical rectangle] Continue public- and private-sector recruitment efforts to expand the health care workforce.

[black vertical rectangle] Promote advanced nursing education that keeps pace with market demands.

* Research and data imperative; sample strategies:

[black vertical rectangle] Identify and fund federal and nonfederal agencies to collect workforce data.

[black vertical rectangle] Create a clearinghouse to make national and regional workforce data accessible to various stakeholders.

INSTITUTIONAL IMPERATIVES

Not all activities are suited to the national level. Roles for local and regional entities in addressing the shortage are clearly supported by the reports we examined. The reports' major recommendations or solutions were relevant to institutional involvement focused on the work environment-concerns about working conditions, patient safety, the use of technology, and innovations in patient care. Also noted was the need for effective and responsive leadership. Data from the reports point toward two institution-level imperatives.

* Work climate imperative; sample strategies:

[black vertical rectangle] Ensure satisfactory basic salaries and safe working conditions.

[black vertical rectangle] Integrate technology to help nurses work more efficiently and improve patient safety.

* Leadership and innovations imperative; sample strategies:

[black vertical rectangle] Create academic and service partnerships to reform provider education and utilization.

[black vertical rectangle] Establish leadership development opportunities with an emphasis on innovation and change management.

INDIVIDUAL NURSING IMPERATIVES

Practicing nurses must also commit to influencing change and ensuring effective clinical outcomes. With this in mind, we include two final imperatives.

* Involvement imperative; sample strategies:

[black vertical rectangle] Commit personal time to and seek a voice in organizational and professional decision making.

[black vertical rectangle] Actively support colleagues who participate in workforce initiatives.

* Adaptive imperative; sample strategies:

[black vertical rectangle] Reflect on personal attitudes toward change.

[black vertical rectangle] Recognize that the profession of nursing will continue to change.

The purpose of our research was to examine these 15 reports, with the end result being synthesized information that can be used to direct action strategies. Out of this work, our gap analysis was developed, which provides new knowledge and a platform from which a comprehensive action plan can be derived. The imperatives, carved from the collective recommendations within the reports, frame the organizing structure around which sound strategies can be determined devised by groups and individuals. We now challenge key stakeholders to use these findings as the starting point for transformational change.

Table. Gap Analysis of Workforce Problem- Solution Themes*When five or more reports made note of a particular problem, we referred to it as a "problem theme." When five or more reports made note of a particular solution, we referred to it as a "solution theme."+In some cases, problems were identified but no solutions to them were proposed. In other cases, solutions were proposed that didn't address any of the identified problems. In such instances, we termed the absence of corresponding problem or solution a "gap."++From the problems identified, solutions were expanded to include staffing ratios, salary and benefits, worker safety, and practice model development.[S]Solutions relate to outcomes, practice, education and demonstration-project evaluation, staffing effectiveness, and national workforce data expansion.[//]Although technology was mentioned as a solution in only three reports, we considered it a "primary theme" because state-of-the-art technology has the potential to bring about large-scale efficiency gains in health care.

REFERENCES

Initially, five Robert Wood Johnson (RWJ) executive nurse fellows who were also involved in the RWJ Colleagues in Caring (CIC) initiatives (see Who Is an RWJ Executive Nurse Fellow? page 69) and five nurse experts from CIC projects gathered to discuss some 35 reports that addressed the health care workforce shortage. These panelists had content and experiential knowledge in work analysis and design, performance and competency measurement, and workforce trends; all were interested in gaining insight into the workforce shortage problem. During this meeting, researchable questions were generated, and a formal research team was established.

Rather than conduct an exhaustive review of all possible documents, we selected reports written from different vantage points (see Characteristics of the Reports, page 72). At this time inclusion criteria were established, and 15 of the 35 reports met the requirements. They

* addressed the workforce shortage from a national perspective.

* focused primarily on nursing.

* were issued between 2000 and 2002.

* had face validity (that is, they were judged by the expert panel to be relevant to this study).

* represented the perspectives of key stakeholders (for example, government and accreditation agencies, labor and professional organizations, trade groups, and foundations).

* authorship and the sponsoring body, including the people served by the report and the need cited for it.

* all data cited by the authors, including statistics, type (demographic, workforce, projection, or other), and primary source.

* the themes of each section or paragraph.

* any calls to action, recommendations, or "next steps," noting, where possible, who was responsible for taking action on the given recommendations.

Themes were derived from both the quantitative data and a comprehensive content analysis across the 15 reports. However, with the exception of technology, no theme was included unless it was found in at least five of the 15 reports. In keeping with qualitative methods, the team members kept reflective or field notes in order to capture the essence of ideas and analytic insights. The themes that cut across reports were characterized as either problems associated with the workforce shortage or solutions to the shortage. Our findings are displayed in Gap Analysis of Workforce Problem-Solution Themes, page 73.

Who Is an RWJ Executive Nurse Fellow?

The Robert Wood Johnson Executive Nurse Fellows Program is an advanced leadership program for nurses in senior executive roles in health service, public health, and nursing education who aspire to help lead and shape the U.S. health care system.

The Colleagues in Caring initiative is a national program funded by the Robert Wood Johnson Foundation. Those nurses involved in the initiative aim to help build systems of workforce development with the capacity to adapt to the rapid and continual changes in the nation's health care system.

For More on This Research [horizontal ellipsis]

Michael Bleich and Peggy Hewlett are invited to present findings from the research described in this article to the National Advisory Council on Nurse Education and Practice (NACNEP) this month. Their written remarks will be included in the NACNEP's third report to the Secretary of Health and Human Services and the U.S. Congress, which will be available to the general public in November.

The Reports Studied

The following are reference citations for the reports on the workforce shortage that were examined in this analysis.

* American Organization of Nurse Executives. Perspectives on the nursing shortage: a blueprint for action. Washington, DC; 2000.

* Fullerton NJ, Toossi M. Labor force projections to 2010: steady growth and changing composition. Monthly Labor Review 2001;124(11):21-38.

* Gelinas L, Bohlen C. Tomorrow's work force: a strategic approach. Irving, TX: VHA; 2002.

* Joint Commission on Accreditation of Healthcare Organizations. Health care at the crossroads: strategies for addressing the evolving nursing crisis. Washington, DC; 2002.

* Joseph A, Melick J. Health care staffing shortage. New York: Fitch Information Incorporated; 2001.

* Kimball B, O'Neil E. Health care's human crisis: the American nursing shortage. Princeton, NJ: Robert Wood Johnson Foundation; 2002.

* Peter D. Hart Research Associates. The nurse shortage: perspectives from current direct care nurses and former direct care nurses. Washington, DC: Federation of Nurses and Health Professionals American Federation of Teachers; 2001.

* SEIU Nurse Alliance. The shortage of care. Washington, DC: Service Employees International Union; 2001.

* U.S. General Accounting Office. Nursing workforce: emerging nurse shortages due to multiple factors. Washington, DC; 2001.