Driven by unprecedented social and demographic changes, this nursing shortage won't be "fixed" by solutions that worked in the past. Here's what makes this shortage unique-and how you can influence the changes shaping your profession.


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IF YOU'VE BEEN IN NURSING long enough, you've been through nursing shortages before. As in the past, you're putting in longer hours-caring for more patients and trying desperately to keep up. And you're waiting for the reinforcements-new nurses-to ride into town, as they always have.


Well, as the saying goes, that was then, this is now.


Relief may not be on the way this time, and you may have to continue your heroic efforts to keep pace indefinitely.


Welcome to the new nursing shortage.


Today's nursing shortage is unlike any shortage we've experienced before, experts say. Unique labor and population trends are causing massive disruptions in the supply of nurses at the same time the need for nursing care has begun to skyrocket.


In this article, we'll tell you why this nursing shortage calls for different solutions than those that worked in the past. We'll also tell you what you can do to protect yourself from burnout and even increase your job satisfaction in today's demanding health care environment.


Let's start by examining the roots of this nursing shortage.


More patients, fewer nurses

At the heart of today's nurse shortfall are two population groups moving in opposite directions-patients and nurses. As life expectancy in the United States increases, more people are surviving serious illnesses and living longer with chronic diseases. At the same time, more nurses are retiring or leaving the profession before retirement. Some 50% of all nurses working today will reach retirement age within 15 years. (See Doing the Numbers.)


But that's just the start:


* Fewer people are entering nursing because other professions are doing a better job of attracting a new generation of workers, men and women alike. Nurse-researcher Peter Buerhaus argues that the primary factor leading to this nursing shortage is declining interest in nursing among women, who now have many more career options than in the past.


* Hospital restructuring and costcutting in the early nineties eliminated a lot of RN positions, leaving remaining staff overburdened and accelerating the flight of nurses from the profession.


* In a survey conducted by the American Association of Colleges of Nursing (AACN) in 2000, 220 colleges reported 379 faculty vacancies, which contributed to schools' turning away almost 6,000 qualified applicants. The faculty shortage is compounded by the fact that many advanced practice nurses who would have become educators in the past are now opting instead for better-paying positions in clinical and private practice.


* Nursing's public image hasn't caught up to reality. A recent American Nurses Association (ANA) poll documents pervasive public ignorance about what nurses do and how we're educated.


* Outside the United States, many other countries are experiencing nursing shortages, so foreign recruitment is a limited option. The countries from which the United States recruits nurses may be in greater need for nurses than we are, raising both practical and ethical issues.



Tired of "making do"

Burdened with increasingly heavy patient loads, nurses are tired of settling for less and simply "making do."


This dissatisfaction is clearly evident from a multinational study of 43,000 nurses (Aiken, 2001). More than 40% of respondents working in hospitals in the United States reported dissatisfaction with their jobs. Here are some other key findings from that study:


* Only 34% of surveyed nurses reported enough RNs to provide high-quality care in the facility where they work


* Only 43% reported enough support services to get the work done.


* Only 29% reported that their administration listens and responds to nurses' concerns.


* Nurses reported that they're tied up in nonnursing work.


* Nurses who are dissatisfied are more likely to cite unhappiness with their work than with their salaries.



That's not so surprising: None of us entered the profession expecting to get rich. But we did expect to love our work. A British study (Shields, 2001) determined that nurses who report job dissatisfaction have a 65% higher probability of leaving their job.


What do nurses want? A 1999 study by McNeese-Smith found that nurses get satisfaction from providing direct care. The message is clear: Let nurses do the work they love with adequate support staff and the tools they need. If nurses are satisfied with their work, more will stay-and more new nurses will join the ranks.


Widespread dissatisfaction

Unfortunately, myriad factors contribute to widespread dissatisfaction among today's nurses; for example:


* lack of a strong professional practice environment. This includes inadequate collaboration; lack of respect for the nursing role from employers, physicians, and other health care providers; and insufficient compensation for further education.


* high nurse/patient staffing ratios. In a study of adult general hospitals in Pennsylvania published in the fall of 2002, researchers found that for each additional surgical patient over four patients in an RN's workload, the 30-day risk of death increases by about 7% (Aiken, 2002). And each additional patient per nurse is related to a 23% increased risk of nurse burnout and a 15% increased risk of job dissatisfaction.Based on our personal experiences and the reports of Nursing's readers over the years, we've identified these additional factors leading to nurses' dissatisfaction:


* mandatory overtime


* unsafe working conditions leading to errors


* abusive and at times violent work environments


* poor use of advanced technology and a lack of tools-computers, personal digital assistants, and monitoring equipment-to do the job better. For example, automated blood pressure (BP) monitoring systems that document BP save nursing time and improve patient care. Yet many facilities are slow to adopt enough expensive new equipment like this to help nurses do their work better, despite the enormous potential for time and cost savings down the road.


* inadequate compensation for the level of education and skill required for the work


* poor standards of care that lead to below-par care and patient outcomes.



According to a report from the Health Resources and Services Administration (HRSA), only 65% of staff nurses in nursing homes and 67% of staff nurses in hospitals report being satisfied with their jobs. The figures are 69% and 73% for public/community health and ambulatory care settings, respectively.


According to the HRSA report, "Non-staff nurses [such as nurse-managers and clinical nurse specialists] who spend more than 50% of their time in direct patient care report higher job satisfaction than staff nurses spending similar amounts of time with patients. This suggests that it is the structure of the job, rather that the composition of the work, that is influencing satisfaction."


No quick fix

With a shortage that's unique, the usual solutions don't apply. Quick fixes such as hiring bonuses and education reimbursement may help in the short run, but they won't solve the underlying issues.


Addressing the core retention issues will also address the key recruitment issues that keep candidates from entering the profession. This approach is the only long-term solution to the nursing crisis.


Nurses need work environments with strong professional practice models that value their work and recognize their impact on patient outcomes. For example, shared governance or magnet hospital models involve nurses in directing professional nursing practice. In these models, nurses set standards of practice for nursing, evaluate whether these standards are being met, and have a high level of independence in decision making.


Nurses also need:


* adequate staffing and resources so that they can perform all of the essentials of their work, not just the bare bones


* salaries and benefits commensurate with their responsibilities


* a professional approach to staffing issues. (What other profession requires mandatory overtime?)



A professional environment and strong job satisfaction will create working conditions that draw people to nursing as a career.


What's being done?

Government and industry, as well as professional nursing organizations, are mounting major efforts to combat the shortage. Federal and state governments, for instance, are enacting legislation to improve the work environment for nurses and help pay nursing tuition.


Initiatives include legislation geared to stop mandatory overtime, protect whistle-blowers, and develop minimum nurse/patient ratios. In California, legislation limiting the nurse/patient ratio to a maximum of 1:6 is scheduled to go into effect in July. After 12 months, the maximum ratio will be 1:5. Note that these are maximum ratios, which can be adjusted to lighten the patient load for nurses caring for acutely ill patients who need more nursing time.


In the recent major study of Pennsylvania hospitals, researchers voiced strong support for the California initiative, noting the strong relationship between staffing and patient mortality. (Aiken, 2002).


Last June, the Department of Health and Human Services awarded $30 million in grants to increase the number of qualified nurses and the quality of nursing services across the country. In August, President Bush signed into law the Nurse Reinvestment Act, which includes measures such as scholarship funding and loan repayments for nursing students. However, Congress hasn't yet appropriated funding.


In private industry, Johnson & Johnson has launched the Campaign for Nursing's Future. This initiative dedicates $20 million to national advertising and promotion to attract people to the profession.


Although it's too early to gauge the success of such initiatives, some states are reporting increases in nursing school aplications. In Pennsylvania, for example, admissions to state nursing schools rose from 3,500 to 4,350 (a 24% increase) betwen 2000 and 2001, reversing a 5-year decline.


Currently, 58 hospitals have earned the Magnet Award for Nursing Excellence, administered by the American Nurses Credentialing Center. This program, which rewards strong professional practice environments, helps recruit and retain nursing staff, draws patients to the facility, helps improve patient outcomes, and assists with achieving better finances for the institution. More hospitals apply for magnet hospital status every year.


In many instances, hospitals and schools of nursing are working together to develop programs to promote the profession and reward nurses. An example is the Cameos of Caring program involving the University of Pittsburgh (Pa.) School of Nursing and 33 surrounding hospitals. In this initiative, the achievements of practicing nurses are recognized annually through a well-publicized recognition/awards program.


Nursing organizations are working together on three major initiatives:


* Nursing's Agenda for the Future, supported by 19 organizations, involves strategies to ensure quality patient care and to address causes of the nursing shortage.


* The Tri-Council for Nursing focuses on stemming the nursing shortage through leadership initiatives in education, practice, and research. Members include the AACN, ANA, American Organization of Nurse Executives, and National League for Nursing.


* Nurses for a Healthier Tomorrow, joined by 41 nursing and health care organizations, is waging a communication campaign to attract people to the nursing profession.



Getting personal

But all these efforts represent only part of the solution. Another part involves your own efforts to improve the professional environment at your facility and to care for yourself so that you can continue your work in nursing with a positive outlook. You can also make a difference outside your unit and facility. (For more suggestions, see Advocating Beyond the Walls accompanying this feature at under "Journal contents," January 2003.)


In June 2002, researchers at the ANA convention presented results of a study demonstrating that nurses aren't good at caring for themselves. This is something you can control. Although you can't eliminate all the stressors in your life, you can change how you perceive and react to them. Do a self-assessment of the stressors you experience in the workplace and how you cope (or don't). Then look hard at which stressors you can control or change and which ones are beyond your control.


Next, ask yourself what resources you can realistically use to manage stress. For example, join a fitness center or engage in some sort of exercise daily. Ask a stress-management expert to present an educational program on relaxation techniques.


Professional growth

Identify the knowledge and skills you need to raise your level of expertise in your current position while keeping an eye on the future. Besides boosting your self-esteem, this will increase your job satisfaction. Ask your staff-development educator to present an educational session or provide resource materials on topics related to your needs, such as delegation and conflict resolution.


Don't shortchange yourself and your career by overlooking the many educational opportunities available for nurses. Earn continuing-education credits, get certified in your specialty, or pursue a higher academic degree. Nurses who accomplish these goals consistently report feeling more confident and satisfied, personally and professionally.


Recasting the environment

Nurses identify their work environment as the top cause of job dissatisfaction. You can take control by focusing your energy in your unit or by broadening your reach by working on nursing and hospital committees. Whether working for change in your unit or throughout the facility, consider these suggestions:


* Make your criticisms constructive. Bring problems and your ideas for solutions to the attention of colleagues and your nurse-manager.


* Compliment colleagues on a job well done. In a visible area, post thank-you notes from patients or families. By recognizing your colleagues' contributions, you contribute to a positive atmosphere.


* Develop an orientation packet for new graduates, nurses who float to the unit, and agency or travel nurses. Make helping newcomers a tradition in your unit.


* To foster collegiality, ask staff members from different ethnic and religious backgrounds to talk about their culture and beliefs, especially regarding health, illness, and end-of-life issues.


* Ask your nurse-manager to investigate creating a shared governance model of nursing practice, which fosters nurse autonomy and decision making.


* Work toward achieving magnet hospital status for your facility. Show managers and administrators the evidence that nurse recruitment and retention improves in facilities that foster strong nursing practice environments.



One similarity

Although the dynamics of this shortage differ from those driving previous shortages, one thing hasn't changed: Nurses will still pull together to care for their patients. And that creativity and dedication to patients, the profession, and ourselves can help nursing weather this crisis and become stronger as a profession.


Doing the numbers

Less supply, more demand


* By 2020, the shortage will number an estimated 808,400 nurses. (HRSA, July 2002)


* The population over age 65 is expected to double from the year 2000 to 2030-from about 35 million to 70 million. (U.S. GAO Report, July 2001)


* People over age 85 are currently in the fastest-growing age-group. (HRSA, July 2002)


* The number of RNs not employed in nursing increased by 28% between 1992 and 2000. (HRSA, July 2002)


Fewer nurses entering the profession


* The number of RN graduates has fallen annually from 1995 to 2000, resulting in 26% fewer RN graduates in 2000 than in 1995. (HRSA, July 2002)


* The National Council of State Boards of Nursing reported that almost 28,000 fewer U.S.-educated graduates sat for first-time NCLEX in 2001, compared with 1995. (AACN's 2001 Annual Report)


* The RN workforce grew 5.4% from 1996 to 2000, the lowest rise since this statistic was first calculated in 1977. (AACN, 2001a September)


* Since 1995, nursing school enrollment has dropped in all types of entry-level programs (HRSA, July 2002). The exception was a small bump (3.7%) for BSN entry-level programs in the autumn of 2001. (AACN, 2001b December)


Nursing faculties continue to shrink


* In 2000, the average age for doctoral-prepared nursing professors was 531/2. (AACN 2001-2002 Report)


* In Oregon, an estimated 41% of baccalaureate and graduate program faculty are expected to retire by 2005-a pattern that's likely to be repeated throughout the United States. (Oregon's Nursing Shortage, 2001)




* In 1980, most (53%) RNs were under age 40. In 2000, less than one-third (32%) were under age 40. The biggest drop was among RNs under age 30: In 1980, 25% of RNs were under age 30, compared with 9% in 2000. (HRSA, March 2000)


* By 2010, 40% of RNs will be over age 50. (Buerhaus, 2000)




* The proportion of men in nursing increased from 2.7% in 1980 to 5.4% in 2000. The number of men has grown at a faster rate than the total RN population. (HRSA, March 2000)


* About 7.5% of new male nurses left the profession within 4 years of graduating from nursing school, compared with 4.1% of new female nurses. (Sochalski, 2002)


Racial/ethnic background


* The percentage of nurses from racial and ethnic minorities grew from 7% in 1980 to 12% in 2000. This lags far behind the proportion of minorities in the general population, which is about 30%. (HRSA, March 2000)


For complete source citations, see the selected references at the end of the article.



For additional information on the shortage and solutions, plus books, audiotapes, and Web sites related to this article, see our Web site at under "Journal contents," January 2003.




Aiken, L., et al.: "Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction," JAMA. 288(16):1987-1993, October 23/30, 2002. [Context Link]


Aiken L., et al.: "Nurses' Reports on Hospital Care in Five Countries," Health Affairs. 20(3):43-53, May/June 2001. [Context Link]


American Association of Colleges of Nursing: AACN's 2001 Annual Report.


American Association of Colleges of Nursing: AACN's Nursing Shortage Fact Sheet, Washington, D.C., 2001a September.


American Association of Colleges of Nursing: Enrollments Are Rising at U.S. Nursing Colleges and Universities, Ending a Six-Year Period of Decline, Washington, D.C., 2001b December.


American Association of Colleges of Nursing: 2001-2002 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing.


American Nurses Association: Analysis of American Nurses Association Staffing Survey, February 6, 2001.


Bryant, J.: "Hospitals Go Overseas for Nurses," Atlanta Business Chronicle, May 4, 2001.


Buerhaus, P., et al.: "Implications of an Aging Registered Nurse Workforce," JAMA. 283(22):2948-2954, June 14, 2000.


Finding and Keeping Nurses: What Is Working? Study on Recruitment and Retention. National Association for Health Care Recruitment, December 2001.


Hodges, L., et al.: "Taking Political Responsibility for Nursing's Future," MedSurg Nursing. 11(1):15-24, February 2002.


Kimball, B., and O'Neil, E.: Health Care's Human Crisis: The American Nursing Shortage. The Robert Wood Johnson Foundation, Princeton, N.J., April 2002.


Lacy, L., and Shaver, K.: Findings from the 2001 Survey of Staff Nurses in North Carolina, The North Carolina Center for Nursing, May 2002.


McClure, M., and Hinshaw, A. (eds): Magnet Hospitals Revisited: Attraction and Retention of Professional Nurses. Washington, D.C., American Nurses Publishing, 2002.


McNeese-Smith, D.: "A Content Analysis of Staff Nurse Descriptions of Job Satisfaction and Dissatisfaction," Journal of Advanced Nursing. 29(6):1332-1341, June 1999.


Moore, V., and Sharkey, K.: "Magnet Hospitals Going for the Gold in Nursing," Nursing2001. 31(11):82-83, November 2001.


Nursing Workforce: Emerging Nurse Shortages Due to Multiple Factors. U.S. General Accounting Office (GAO) to the Chairman, Subcommittee on Health, Committee on Ways and Means, House of Representatives, July 2001.


Oregon's Nursing Shortage: A Public Health Crisis in the Making. Issue Brief No. 1, Northwest Health Foundation, April 2001.


Peterson, C.: "In Short Supply around the World, the Need for Nurses Grows," Nevada RNformation. 11(1):22, February 2002.


Projected Supply, Demand, and Shortages of Registered Nurses: 2000-2020. U.S. Department. of Health and Human Services, Health Resources and Services Administration (HRSA), Bureau of Health Professions, National Center for Health Workforce Analysis, July 2002.


The Registered Nurse Report. Findings from the National Sample Survey of Registered Nurses. U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA), Bureau of Health Professions, Division of Nursing, March 2000.


"Retention in the National Health Service: The Impact of Job Satisfaction on Intentions to Quit," Journal of Health Economics. 20(5):677-701, September 2001.


Sochalski, J.: "Nursing Shortage Redux: Turning the Corner on an Enduring Problem," Health Affairs. 21(5):157-164, September/October 2002.