Healthcare Workforce Outlook
The Nursing Shortage in
Suggestions for Future Research and
Policy
Prepared for
Council on Gender Parity in Labor and
Education
Written by
Karrie Ann Snyder,
Ph.D.
Center for Women and Work
December 2003
Overview
In
2002, the New Jersey Council on Gender Parity in Labor and Education issued the
report “Women at Work: Achieving Parity on the Job” to highlight barriers to gender
parity in five areas: building trades, financial services, health care, law and
technology. The Council is currently
working on initiatives in each of these areas.
This report explores issues surrounding gender parity in health care,
particularly in regard to the current nursing shortage. Since nursing is a heavily female-dominated
occupation, the shortage has implications not only for the nation’s health care
system but also for women’s experiences in the nursing labor force and the
ability to increase the number of men in nursing. As an initial step in recognizing and
defining workforce issues and barriers to gender parity in New Jersey’s health
care system, this report was developed as an extension of the New Jersey State
Employment & Training Commission’s (SETC) A Unified State Plan for New
Jersey’s Workplace Readiness System. The
Unified State Plan, first introduced in 1992, is an effort to address
the complexities of creating a unified high quality workforce investment
system. The Council strongly believes
that this report will aid
Introduction
The current
nursing shortage, both in
Cost
containment has shifted care from the traditional acute care hospital setting
to ambulatory care centers, community clinics, and nursing homes. Changes in technology have further encouraged
these shifts, leading to a decline in hospital beds and stays. As a result, the level of hospital acuity for
hospital patients has increased. The
combination of these changes has led to an upsurge in job opportunities and
demand for nurses (Minnesota
Department of Health 2002).
The nursing shortage is not limited
to registered nurses, but also includes nursing faculty, licensed practical
nurses, nursing assistants and home health aides. Appendix 1 provides an overview of the
related but distinct nursing professions covered in this report. As evident from Appendix 1, these occupations
are different in terms of training, educational requirements and advancement
opportunities.
This report addresses
the massive and complicated problem of the nursing shortage by reviewing the
current state of the shortage across nursing and related professions, both in
Registered Nursing Shortage
Registered
nurses (RNs) are the largest group of health care providers in the
|
Table
1. Employment Settings of RNs 2002 |
|
|
|
|
|
Hospital |
55.9% |
|
Long
-Term Care |
7.5 |
|
Home
Care |
7.4 |
|
Student
Health |
5.6 |
|
MD/AVN
Practice |
5.0 |
|
Nursing
Education |
1.9 |
|
Other |
16.6 |
|
Data
from the |
|
This nursing shortage
is characterized by a decreased supply of nurses coupled with an increased need
for more nursing professionals. Demand
for nurses in part will increase due to the inevitable aging of the baby boomer
generation. According to Buerhaus,
Staiger and Auerbach (2000a): “the impending decline in the supply of RNs will
come at a time when the first of 78 million baby boomers begins to retire and
enroll in the Medicare program in 2010.”
Further, there is a
significant shortage of RNs with Bachelor’s degrees. Registered nurses can become licensed through
2-year (Associate’s Degree), 3-year (Diploma) or 4-year (Bachelor’s of Science
in Nursing Degree) programs (see Appendix 1).
Unlike past shortages, employers are not simply reporting a lack of
nurses, but a lack of Bachelor-trained nurses (Keating and Sechrist
2001). According to the American
Association of Colleges of Nursing (AACN) (2000), “To meet the more complex
demands of today’s health care environment, a federal advisory panel has
recommended that at least two-thirds of the basic nurse workforce hold
baccalaureate or higher degrees in nursing by 2010.” In fact, Aiken, Clarke, Cheung, Sloane and Silber (2003) find that a ten percent increase in the
percentage of nurses with Bachelor’s degrees on a hospital’s staff is
“associated with a 5% decrease in both the likelihood of patients dying within
30 days of admission and the odds of failure to rescue” (pg. 1617). These researchers find that the percentage of
RNs with a Bachelor’s degree within a hospital was more important for patient
outcomes than the nurses’ years of experience.
Although the percentage of Bachelor-trained
RNs has increased from 22 percent in 1980 (AACN 2001) to 32.7 percent in 2000
(see Table 2), the percentage of Bachelor-trained RNs still falls well under
the federal guideline. In
|
Table
2. Highest Level of
Educational Attainment of RNs 2000 a |
||
|
|
|
|
|
Associate’s
degree (2-year) |
34.3% |
31.7% |
|
Diploma
(3-year) |
22.3 |
40.7 |
|
Bachelor’s
degree (4-year) |
32.7 |
27.2 |
|
Master’s/
Doctorate degree |
10.2 |
9.0 d |
|
a Data from 2000 unless
otherwise noted. b
Data
from Health Resources and Services Administration (2001b), U.S. Department of
Health and Human Services, page 6.
Data for 2000. c Data from the d
Data
from Health Resources and Services Administration (2000), U.S. Department of
Health and Human Services, page 36.
Data for 1996. |
||
In fact, the enrollments in Bachelor’s degree nursing programs have been declining over the past decade. “Since 1995, enrollments in entry-level baccalaureate programmes in nursing have declined by 21.1 percent and the numbers of graduating nurses who took the national licensure examination decreased by 20 percent from 1995 to 2001” (Goodin 2003). The lack of RNs with Bachelor’s degrees is important because a Bachelor’s degree is the prerequisite for many advanced specialties that require graduate-level training including clinical nursing specialist, nurse practioner, midwife and certified anesthetist.[4] On a positive note, enrollments in Bachelor’s degree nursing programs did climb in 2001 due to increased funding for nursing students and improved recruitment efforts by schools (AACN 2001). Yet, Master’s degree nursing programs are struggling to maintain current levels and programs that allow non-Bachelor RNs to obtain a Bachelor’s degree are reporting decreased enrollments (Goodin 2003, AACN 2001).
Reasons for the Registered Nurse Shortage
The Aging of the Registered Nurse Workforce
The changing
age composition of the RN workforce is the primary reason cited by many
researchers for the impending health care crisis (Buerhaus, Staiger and
Auerbach 2000a). Over the last few decades, the RN workforce
has aged more rapidly than most other occupations. The mean age of RNs increased 4.5 years
between 1983 and 1998 from 37.4 to 41.9 years of age (Buerhaus, Staiger and
Auerbach 2000a). Also, during this time
period, the percentage of RNs under 30 years of age fell by 41 percent compared
to only a one percent decline for all other occupations (Buerhaus, Staiger and
Auerbach 2000a). This trend is expected
to continue, with the predicted average age of a RN in 2010 of 45.4 years of
age (Buerhaus, Staiger and
Auerbach 2000a). Nationally, in 2002 only 31.7 percent of RNs were under 40
years of age and only 18.3 percent were under 35 years of age (NJCCN 2003a)
(see Table 3).
|
Table 3. Age Composition of RNs 2002 a |
||
|
|
U.S.b |
|
|
RNs less than 30 years of
age |
9.1% |
5.5% |
|
RNs less than 35 years of
age |
18.3 |
12.3 |
|
RNs less than 40 years of
age |
31.7 |
23.9 |
|
a Data from 2002 unless
otherwise noted. Data from the b Data from the |
||
Furthermore, many
current RNs are reaching retirement age.
In 1996, 49 percent of RNs nationally were baby boomers (Minnick 2000,
pg. 211). As this cohort retires, the
effect on the supply of nurses will be devastating. By 2005, baby boomer nurses will begin to
retire at age 55— the age at which RNs historically begin to reduce their
participation in the labor market (Minnick 2000, pg. 211). And by 2010, almost all of the baby boomer
generation will be in their retirement years (Minnick 2000, pg. 211).
Like the rest of the
nation,
Gender Socialization
The aging of the workforce results in part due to younger women and men not choosing nursing as a career. Although men and women still largely remain in gender-segregated occupations, opportunities in male-dominated industries have begun to open up to women. As a result, younger women are less likely to choose nursing (Staiger, Auerbach and Buerhaus 2000). Women graduating from high school in the late 1980s and 1990s were 30 to 40 percent less likely to become RNs compared to those who graduated in the 1960s and 1970s (Staiger, Auerbach and Buerhaus 2000). In addition, the lack of interest in nursing, particularly among younger women, can be attributed to the poor image of nursing presented in the media. Although the media’s impact has not been systematically studied, the media’s portrayal of nurses as doctors’ handmaidens has reinforced myths of job instability and presented nursing as “dirty work” (Nevidjon and Erickson 2001). These negative images may keep younger people from choosing nursing as a profession.[5] In addition, some researchers find that guidance counselors dissuade young people, both men and women, from entering nursing or encourage high-achieving students to become doctors instead (Boughn 2001; Gabriel 2001; Goodin 2003).
The image of nursing as a female occupation also contributes to the very small proportion of men in the nursing workforce. Although the percentage of men choosing nursing has increased from 4.9 percent in 1996 to 5.4 percent in 2000 (HRSA 2001b), the percentage of men still remains staggeringly low (see Table 4). Nursing is considered to be “women’s work” which dissuades men from choosing nursing as a career (Hemsley-Brown and Foskett 1999; Male Nurse Magazine 2003). In addition, male nurses are often stereotyped to be homosexual or overly feminine (Farella 2003; Male Nurse Magazine 2003) which also discourages men from choosing nursing as a career.
|
Table
4. Gender Composition of
Nursing Professions 2000 a |
||
|
|
Percentage Female |
Percentage Female |
|
RNs |
94.1%b |
96.6% c |
|
LPNs |
94.9 d |
96.2 c |
|
Nursing
Assistants (includes
orderlies and attendants) |
90.0 d |
no data available |
|
Home
Health Aides |
79.0 d |
no data available |
|
a Data for 2000 unless
otherwise noted b Data from the Health Resources and Services
Administration, Bureau of Health Professions, U.S. Department of Health and Human
Services (2001b), page 4. Data for 2000. c Data from the d
Data
from the Health Resources and Services Administration, Bureau of Health
Professions, U.S. Department of Health and Human Services (2000), pages 42,
93-4. Data for 1998. |
||
Researchers have also
found instances of gender discrimination in the recruitment of male nurses into
nursing programs such as the lack of men being used in recruitment materials by
schools. For those men who do decide to
enter a nursing education program, gender discrimination can begin almost
immediately from both peers and teachers.
Even the textbooks required for nursing courses often make no mention of
male nurses, only male patients (Male
Nurse Magazine 2003). While men make up approximately thirteen
percent of nursing students, they have a higher dropout rate then female
students—eight percent for male nursing students and four percent for female
nursing students (Male Nurse
Magazine 2003). Men who become nurses may face resistance in
the workplace from other nurses, administrators and patients (Farella 2000; Hilton 2001; Male Nurse Magazine
2003). While some have noted that gender
discrimination against men in nursing is weakening (Hilton 2001), it is still
an issue that affects the retention rates of male nurses, as male nurses leave
the nursing profession at a rate double that of their female counterparts (Male Nurse Magazine 2003).
Further, job satisfaction is far lower for male nurses than for female
nurses. For newer nurses, the job
satisfaction rate is 67 percent for men compared to 75 percent for women. For nurses who have more established careers,
job satisfaction rates decline to 60 percent for men and 69 percent for women (Male Nurse Magazine 2003).
In addition to gender socialization, which
discourages potential workers from choosing nursing as a career, post-baby
boomer cohorts are significantly smaller, creating a relatively smaller pool of
applicants. Nursing has often been a
popular career choice for those wanting to switch or start a career later in
life.[6] While women under 25 years of age are less
likely to choose nursing than their predecessors, older women are as likely to
choose nursing as earlier generations.
Since, post-baby boomer cohorts are smaller than previous generations
(Auerbach, Buerhaus and Staiger 2000), increasing the supply of nurses by
drawing on people choosing nursing later in life is unlikely. “As of the 1990 census, there were 77 million
American baby boomers compared with just 44 million Generation Xers, creating the smallest pool of entry-level workers
since the 1930s” (Nurses for a Healthier Tomorrow 2001).
As evident in the previous section, the reasons for the nursing shortage are complex including demographic shifts in the population, expanding career opportunities for women, continued lack of recruitment of men, feminized stereotypes of nursing, the poor public image of nursing and the impending aging and retirement of the baby boomer generation. Yet, recruitment is only part of the equation. Since the ranks of RNs are shrinking, job satisfaction and retention among currently employed RNs are becoming increasingly important. The rise of managed care leading to shorter hospital stays for patients and the reality of fewer nurses have led to intensified work loads and RNs spending more time doing administrative tasks and supervising other types of health care personnel. RNs are spending less time caring for people (ANA 2001)—the reason many entered nursing. Although most licensed RNs (81.7 percent) work in health care, retention is an increasingly important concern (HRSA 2001a). Studies have linked RNs’ intentions to leave a current position to increased patient loads (Aiken, Clarke, Sloane, and Silber 2002). A national survey by the American Nurses Association (ANA) finds that nurses are reporting increased patient loads along with what nurses perceive to be “a dramatic decrease in the quality of patient care”(ANA 2001, pg. 5). Seventy-five percent of nurses in this study “feel the quality of nursing care has declined in their work setting in the last two years” (pg. 6). A major reason for this decline in nursing care is “inadequate staffing.” Many nurses who responded to this survey report skipping breaks to care for patients, working mandatory overtime and feeling exhausted and discouraged at the end of the day. An alarming 41.5 percent would not feel confident having someone close to them being cared for at the place they work (pg. 11). As the shortage further increases, as it is predicted to do, turnover rates among employed nurses due to increased workloads, decreased job satisfaction and forced overtime,[7] the RN shortage could become even more acute. In addition, many current nurses who could be a potential source of information and mentors for prospective nurses do not consider nursing to be a good career choice. According to the ANA (2001) survey, 54.8 percent of respondents would not recommend nursing as a career to friends or their children (pg. 12).
Nursing Faculty
In addition to the
shortage of RNs, there is also a nursing faculty shortage. At a time when more RNs are desperately
needed, there are fewer faculty members.
A 2000 survey by the American Association of Colleges of Nursing (AACN)
found a 7.4 percent faculty vacancy rate (Trossman
2002). According to an AACN survey in
2002, 5,283 qualified applicants were not accepted into Bachelor’s, Master’s
and Ph.D. programs. Almost 42 percent of
schools reported that not enough faculty members was a main reason for not
accepting qualified applicants (AACN 2003).
The aging of the RN
workforce clearly impacts nursing faculty.
From 1993 to 2001, the percent of faculty over 50 years of age increased
from 50.7 percent to 70.3 percent (
Licensed Practical Nurses
Although
the shortage of RNs, particularly those with Bachelor’s degrees, has received the
most scholarly, policy and public attention, a shortage among Licensed
Practical Nurses (LPNs) is also occurring.
However, less research on these fundamental care providers exists. They provide bedside care and in some states
can administer prescription drugs and start IVs (BLS 2002). In 2000, there were 700,000 LPNs (BLS 2002) making LPNs the second largest
health care occupation in the United States (Minnesota Department of Health
2002). The American Health Care
Association (ACHA) reports a 14.6 percent vacancy rate for LPNs in nursing
facilities in 2001 (Minnesota Department of Health 2002). As with RNs, this vacancy rate exceeds the
crisis threshold of ten percent.[8]
While the RN shortage
is more acute, the LPN shortage is also anticipated to persist long-term. As with the RN shortage, the reasons for this
shortage are complex. Some reasons
undoubtedly contribute to the shortages of both LPNs and RNs such as the poor
image of nursing. Similarly, men, a
potential source of nurses, do not choose nursing as a career either as a RN or
LPN. In
|
Table 5. Age Composition of LPNs 2002 |
|
|
|
LPN’s in |
|
LPNs less than 30 years of
age |
5.1% |
|
LPNs less than 40 years of
age |
21.8 |
|
LPNs less than 50 years of
age |
55.0 |
|
LPNs over 50 years of age |
45.0 |
|
Data
from the |
|
The effect of the age
composition of the LPN workforce on the LPN shortage has not been as systematically
studied as the consequences of the aging of the RN workforce. However, like the RN workforce, LPNs in
Also, there has been
less systematic attention to enrollment figures for LPN training programs. LPNs must complete a one-year degree program
and pass a certification examination.
Data is not readily available on these enrollments. These enrollment figures are important
because they help to estimate the future supply of LPNs. Furthermore, the high turnover of LPNs also
contributes to the shortage. According
to the American Health Care Association (AHCA), the annualized turnover rate
for LPNs is 54 percent (Minnesota Department of Health 2002). However, more systematic study is needed to
determine the impact of high turnover rates on the shortage. As the second largest health care occupation,
the continuing shortage of LPNs could cause a crisis in health care as baby
boomers enter retirement and Medicare programs.
Currently, 48 percent of LPNs in
Nursing
Assistants and Home Health Aides
Nursing assistants
(NAs) and home health aides are the front lines of the health care system
providing many vital caring services including changing linens, bathing and
assisting patients. According to the
Bureau of Labor Statistics (2002), in 2000 there were 2.1 million health care
aides including 1.4 million nursing assistants, 615,000 home health aides and
65,000 psychiatric aides. However, these
numbers may be underreported since many assistants, particularly home health
aides, are privately hired and they may not appear in federal statistics (Stone
2001, pg. 11). As Appendix 1 depicts,
experience, training or education credentials are not often required to perform
such work, although some employers do require certified or trained nursing
assistants. Along with RNs and LPNs,
long-term health care facilities are reporting shortages of these
paraprofessionals (Stone 2001, pg. 13).
An AHCA report found that in 2001, the vacancy rate for nursing
assistants was 12 percent (Minnesota Department of Health 2002, pg. vii).
The demand for nursing
assistants is expected to grow particularly for home health aides (BLS 2002)
partly due to the higher retirement incomes of baby boomers. Due to increased incomes, those facing
long-term care will have greater options including hiring home health aides
(Manchester 1997 as cited in Stone 2001, pg. 15). Also, due to smaller numbers of children and
more women in the labor force, informal forms of family care may be harder to
come by resulting in the need for paid health care providers (Stone 2001, pg.
15-16). As a result, the demand for home
care providers is predicted to increase 74.6 percent between 1996 and 2006 and
25.4 percent for nursing home aides during the same time period (Stone 2001,
pg. 16).
The increased demand
for nursing assistants is further exacerbated by high turnover rates.[9] Turnover rates range from ten percent to over
140 percent depending on the health care setting (e.g., home care, nursing
home) and region (Stone 2001). Research
also suggests that these rates do not reflect people simply switching jobs. For example, the Department of Elder Care in
High turnover rates
are partly the result of the poor image of the nursing assistant occupation and
very low wages (Stone 2003). Some
suggest that the supply of nursing assistants is very vulnerable to swings in
the economy. When jobs are plentiful
people may look outside of these low-skill health care jobs (Stone 2003). Similar to the RN and LPN shortages, the NA
shortage is the result of a complex set of factors including job satisfaction,
other available opportunities, and the changing age composition of the
population increasing the demand for these paraprofessionals. New Jersey Health Initiatives estimates that
between 1998 and 2008
The nursing shortage,
if not curtailed, will reach epidemic proportions both nationally and in
Many proposed solutions have been suggested
and implemented including expanded recruitment efforts by nursing education
programs; increased funding of nursing programs; and media campaigns to improve
the image of nursing. In 2002, the
Federal Government passed the “Nurse Reinvestment Act.” The Act outlines a comprehensive program to
increase the supply of nurses in the long-term including the development of a
national public service campaign to improve the image of nursing, educational
loan repayment programs, and the development of career ladders within the
nursing profession. Although there have
been many policies suggested and enacted at the organizational, local, state
and national levels, most of these efforts have not been systematically
evaluated.
Most experts agree
that two types of policies will be needed to handle the expanding crisis: one,
ways of dealing with the crisis that allow for the realties of a reduced
nursing staff particularly among RNs and, two, policies that seek to expand the
supply of nurses and related professions.
Undoubtedly, both types of strategies will be needed to counteract the
consequences of understaffed health care facilities. The final section of this report focuses on
strategies to increase the supply of RNs and related nursing occupations,
specifically long-term strategies, to encourage more people to enter the
nursing profession. This final section
combines policy suggestions with proposed research agendas. The proposed research agendas will help to
determine the best way that policies and programs can be enacted as well as
evaluated.
The existing need for faculty members in the nursing professions has
been documented and raised earlier in this report with over 5,200 qualified
applicants not accepted into Bachelor’s, Master’s and Ph.D. programs and nearly
40 percent of schools reporting that the lack of faculty is the main reasons
for not accepting these applicants (AACN 2003).
Research are strategies are needed to address the diminished capacity
in the teaching profession as well as to identify pools of individuals who may
be interested in pursuing graduate studies and teaching careers.
Career Ladders
As
evident from Appendix 1, nursing occupations differ immensely in the training
required. Requisite education ranges
from no training or even a high school diploma for some nursing assistants to
doctorate degrees for nursing faculty.
If there is lack of nurses, particularly at the RN level, it may make
sense to recruit from within the health care industry. Nationally, 83 percent of licensed RNs work as nurses (Minnick 2000). Within
Certified Nursing Assistant to Licensed Practical Nurse Most people enter nursing because they want to help others. The potential income is not is the primary reason that women enter nursing (Boughn 2001). However, other researchers suggest that the supply of nursing assistants is very much tied to swings in the economy that influence the availability of other types of jobs (Stone 2001). If entry-level nursing assistants saw the potential for upward mobility would that increase people entering this position or at least help to retain those who are nursing assistants? More research, including national surveys of CNAs (certified nursing assistants) and on-site interviews with home health aides, is needed to understand if nursing assistants would take advantage of LPN training, if available, as well as the needs of this population for such programs in terms of flexibility, financial assistance, job placement, ESL training and so forth. In addition, these interviews and surveys could be used to gain a more nuanced understanding of the workplace concerns and job satisfaction of nursing assistants. This is vital because the shortage of nursing assistants has been strongly linked to high turnover rates among nursing assistants and home health aides.
Licensed Practical Nurse to Registered Nurse A second important career ladder would be
the transition of LPNs to RNs. The
expansion and increased flexibility (such as flexible hours or the combination
of work and school) of programs geared toward LPNs wanting to become registered
nurses could help these nurses obtain an RN license. The RN population has been better studied in
terms of why they chose nursing as a career.
More research is needed to understand the career perceptions of LPNs as well as their satisfaction on the job. Do individuals become LPNs with the intention
of becoming RNs? What factors encourage
or discourage this transition? Of New
Jersey RNs surveyed in 2001, only 7.1 percent had completed an LPN program
(NJCCN 2003b). Although 71 percent of
actively licensed LPNs in
Career ladders as the ones proposed above would serve a dual purpose. One, the ladders would increase the supply of RNs because of upward mobility from within the health care profession. Two, career ladders would encourage higher retention rates among all types of nurses because of increased job satisfaction due to the opportunity to expand job skills and responsibilities.
Recruitment
of Male and Minority Nurses
Most
nurses are Caucasian and the overwhelming majority are women. Although Caucasians were 71.8 percent of the
Table
6. Racial and Ethnic
Composition of Nursing Professions 2000 a |
|||||
|
|
Non-Hispanic White |
Black |
Hispanic |
Asian and Pacific Islander |
Native American |
|
|
71.8% |
12.2% |
11.4% |
3.9% |
0.7% |
|
RNs
- |
86.6 |
4.9 |
|||