If you work as a health care professional, and especially if you're a nurse, you don't have to be told there's a big problem with staffing your health care facility. Whether it's a shortage of personnel in your field or the unwillingness of health professionals to work under the terrible pressures and circumstances that exist today is still being debated. What is not being debated is that a shortage of nurses IS on its way, and, in many locations, is already here.

One of the first organizations to take some action on the problem was the Federation of Nurses and Health Professionals, which made an announcement in early June 2000 that it was committing its energies and resources to finding a remedy for the emerging shortage of nurses available (or willing) to work in the nation's hospitals. At the annual FNHP professional issues conference in Washington, D.C., AFT president Sandra Feldman called the nurse shortage "a health care emergency" and blamed it on an "epidemic of disillusionment among health care professionals" that's as serious as an epidemic of disease among patients. The FNHP gave some background to that shortage alert in a first-of-its-kind "health care workforce almanac" that the union released in June, which highlighted some of the ominous trends:

• There are more than 2.1 million registered nurses but an anticipated need for 450,000 more by the year 2008.
• Enrollment in nursing schools has declined drastically in every region of the country. Between 1998 and 1999 alone, there was a 4.6 percent drop, marking the sixth consecutive drop in as many years.
• Real wages for RNs have actually dropped despite the need to hire more nurses. The median weekly wage had dropped from $792 in 1993 to $750 in 1999.
• Hospital admissions have risen steadily over the past several years, nearly 3 percent between 1994 and 1998.
• The average age of registered nurses is 42, with more than 35 percent between the ages of 40 and 49.

The gravity of that last statistic became the focus of a study released in JAMA shortly after the FNHP conference. The study, "Implications of an Aging Registered Nurse Workforce," by Peter I. Buerhaus, Ph.D., RN, et al., points out that as the average age of working RNs increased from 37.4 years to 41.9 years between 1983 and 1998, the proportion of the RN workforce that's younger than 30 years decreased from 30.3 percent to 12.1 percent. "[T]he actual number of working nurses younger than 30 years decreased by 41 percent," said the study. In contrast, the total labor force in the U.S. younger than 30 decreased by less than 1 percent. During that same 15-year period, RNs working in hospitals increased in age by 5.3 years, while the average age of the U.S. work force as a whole increased by fewer than two years. So RNs working in hospitals are getting older on the average, and younger nurses are going elsewhere.

The JAMA study notes that, within the next 10 years, the average age of RNs is forecast to be 45.4 years and, over the next two decades, the largest number of RNs will be between age 50 and 69 years. "The total number of full-time equivalent RNs per capita is forecast to peak around the year 2007 and decline steadily thereafter as the largest cohorts of RNs retire. By the year 2020," says the study, "the RN work force is forecast to be roughly the same size as it is today, declining nearly 20 percent below projected RN work force requirements." Exacerbating the situation is the fact that the number of RNs working full time has already declined 35 percent from 20 years ago.

This aging and shrinking of the RN work force will hit just about the time the aging baby boomers begin to retire and enroll in the Medicare program in 2010, writes Buerhaus from Vanderbilt University in Nashville, Tenn., and colleagues.

"We're all going to be retiring soon," said FNHP senior associate Joni Ketter, who presented a view of the nurse shortage at the Federation of Nurses/United Federation of Teachers' professional issues conference in New York City this fall. "Fifty percent of all working nurses will reach retirement age in 15 years. Who's going to take care of us?"

The analysis of the aging nurse work force came right on the heels of a report from the American Association of Colleges of Nursing, which had found that enrollments in entry-level baccalaureate nursing programs fell by 4.6 percent in fall 1999--the fifth consecutive decline in as many years. The decrease in enrollments was the worst in North Atlantic schools, where entry-level baccalaureate nursing enrollments fell by 7.4 percent in 1999.

At the same time, the AACN found that enrollments in master's degree nursing programs increased in the West (up 6.1 percent), stayed almost unchanged in Southern schools, but fell in the Midwest and North Atlantic states.

Despite statistical analysts saying that the "big" shortage of nurses is not yet here, other observers say that nurse shortages hit both coasts almost two years ago and that shortages are working their way into the middle of the U.S. But news reports show that nurse shortages are dotting the landscape all across the map. The FNHP's Joni Ketter notes that Texas already claims a shortage of 40,000 nurses and that Florida will have a shortfall of 20,000 nurses in 10 years. A quick scan of the health care news from the last six to eight months also tells the story.

• A survey of Maryland hospitals, issued in August 2000, found that the statewide average vacancy rate for hospital nurses grew to 14.7 percent during the first quarter of 2000. That's a dramatic escalation since 1997 when a similar survey found a 3.3 percent vacancy rate. The Maryland Hospitals and Health Systems survey also shows increasing turnover among hospital nurses and a big jump in the number of days it takes to fill an RN vacancy. The state's General Assembly during its 2000 session created the Maryland Commission on the Crisis in Nursing to find ways to address the growing nursing shortage in Maryland; the Commission is expected to have a five-year life.
• In Vermont, a Rutland Regional Medical Center spokesperson told the Rutland Herald in August that "the nursing shortage is real, it's ongoing, and we don't have a clue as to when it's going to end." In the year 2000 alone, Vermont hospitals were slated to spend $1 million advertising vacant positions and "several times that amount on 'temporary' nurses employed by private firms," reported the Rutland Herald.
• The Health Resources and Services Administration announced in August that researchers in New York had found a growing shortage of RNs--specifically, a 25 percent decrease in the number of graduates from nursing programs within the last six years. Researchers at the State University of New York's Center for Health Workforce Studies conducted the study with support from HRSA; they found that "while the total supply of RNs may have been adequate in 1998 and 1999, there were unfilled vacancies for nurses with specific skills and/or experience. For example, hospitals in New York City reported significant difficulty in recruiting peri-operative, critical care and emergency room nurses."
• In Wisconsin, a Milwaukee nursing home administrator reported last spring that she and several other Milwaukee-area nonprofit nursing home administrators had discussed the recruitment of foreign nurses because of the shortage of nurses already hitting long-term care facilities. Milwaukee Jewish Home & Care Center administrator Nita Corre told The Milwaukee Business Journal that she had already begun placing ads in Canada for nurses. A September news item notes that a new president at St. Francis Hospital in Milwaukee, where the Wisconsin FNHP represents all 1,400 employees, has announced the need for more nurses (the hospital has a 12 percent to 15 percent vacancy rate for nurses) and its intention to work with the Wisconsin FNHP.
• In New Jersey, an August report in The Star-Ledger noted that in the previous 20 months the state Department of Health and Senior Services had cited 17 hospitals, for failing to maintain adequate nursing levels--with a penalty of $1,000 for each day of understaffing.

Demand-driven shortage

"We are dealing with a demand-driven shortage," says Ketter. "There's an increase in demand and, up until now, there had been a steady increase in supply." She notes that the demand drivers include expanding opportunities in front-line primary care--like HMOs, home care, outpatient clinics and other community settings; an aging patient population; more baby boomers needing care and fewer "Gen Xers" to provide it; increasing severity of illness of those going into the hospital; more medical technology and the need for health professionals to deal with it; and more people with insurance (although millions still go without). "Complaints are on the increase about the declining quality of care and the need for more licensed professionals," adds Ketter.

The last nurse shortage this country witnessed was in 1986-1988 when vacancy rates were 13 percent to 15 percent. At that time, all-RN staffs were the norm. What drove the shortage then were increased demand due to an aging population; nursing salaries that were flat; and the continuing increase of different career choices for women. What ended that shortage was an increase in nursing salaries and more flexible schedules for nurses.

The demand today is greater than ever, says Ketter. Nursing is the fastest-growing occupation and is predicted to grow 26 percent in six years. By the year 2020, there will be a demand for 1,754,000 RNs, but only 635,000 will be available. "The U.S. will be short 1 million nurses in 20 years."

One glimmer of optimism, offered by the AACN, can be found in the fact that the current and impending nursing shortages are unlike the pervasive nationwide nursing shortage of the mid-1980s. Currently, shortfalls vary "region by region, market by market, depending upon local conditions," says the AACN. The AACN also claims that not "simply more RNs" are needed, but RNs with particular types of training and educational mix. Therein lies the rub. Hospitals and chief nurse officers may state their preferences for bachelor's degree-prepared nurses (70 percent in a 1999 survey among university health systems indicated this preference, says the AACN), but they aren't willing to pay for them. Only 44 percent of the institutions surveyed paid differentiated salaries and only 33 percent applied differentiated role descriptions based on education.

The bachelor-degree-only requirement notwithstanding, associate degree nursing programs accounted for almost 60 percent of new entry-level graduate nurses, according to National League for Nursing 1998 data, and contributed to the aging RN work force. In 1996, graduates of AD programs were 33.5 years old on average versus 28 years for graduates of baccalaureate programs. The current RN work force includes 27 percent with diplomas from hospital-owned diploma programs, 32 percent with ADs, 31 percent with BSNs and 10 percent with master's or Ph.D., reports the AACN.

In 1995, the Pew Health Professions Commission called for the closing of up to 20 percent of AD and hospital diploma nursing programs in favor of bachelor's- and higher-degree nursing programs. Would closing such programs constitute cutting off an important supply of nurses or is it the one sure way to simplify entry into the profession and recognize the need for nurses who have the educational background for today's--and tomorrow's--complicated health care setting?

Last summer, the Forum on Health Care Leadership held a national meeting in Washington, D.C., at which more than 1,000 health professionals--including nurses, nurse executives and decision-makers--for three days discussed the emerging nurse shortage. The conference, titled "A Staffing Crisis: Nurse/Patient Ratios" and sponsored by Cross Country University and CurtinCalls, which is author and nurse Leah Curtin's "interactive scan of nursing and health care," featured dozens of workshops and open sessions to look at every possible angle of this problem. In her keynote address, after giving an overview of health care industry events that led up to this staffing crisis, Curtin concluded that "we don't have a shortage of nurses, only a shortage of nurses willing to work."

"Willing to work" means conditions in the workplace would have to change, said Curtin. In finding methods for recruitment and retention of nurses, you can't overlook some of the basic problems that keep seasoned nurses out of the profession and new recruits at bay: stagnant salaries, poor pensions, mandatory overtime and terrible working conditions. However, the FNHP--through collective bargaining contracts and negotiated labor-management committees--has been addressing these issues for years.

In part II, Healthwire looks at the reasons and remedies for the nurse shortage and its impact on the quality of care.