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A Poor Prognosis for “The Nursing Disease”
There are no such things as incurables; there are only things for which man has not found a cure. - Bernard M. Baruch
Years ago, thousands of us entered the field of nursing - wide-eyed and eager - with the heartfelt desire to nurture the sick and dying. Few other career alternatives for women were as prestigious and paid as well. Years later, we find our numbers dwindling; many are burned out, used up, and dread getting up and going to work. In 2000, more than half of us complained that we were dissatisfied with our jobs.1 The number of individuals passing the national RN licensing exam is down 23% from 1996.2 In fact, 55% of us would not recommend nursing as a career; 23% of us would actively discourage someone from entering the profession.3 Why? What?s happened?
Age
Today, the 2.6 million American nurses (of which, 95% are women) are the largest group of healthcare providers in the country, representing 40% of acute care costs and about 70% of home care costs. Last year, statistics revealed that fewer than one in three nurses were younger than 40 years old (9% of nurses were under 30 and 35% were between 40 and 49). The number of employed RNs has declined in recent years, as has their national unemployment rate (1% in 2000)2 - the lowest in more than a decade. As opportunities for women outside of nursing have expanded and earning power has increased, the shriveling numbers of young women entering nursing have created a narrowing pipeline for the care of the rapidly aging baby boomer population. By 2010, about 40% of nurses will be more than 50 years old. By 2020, a 20% shortfall of full time equivalent RNs will be required to meet demand.2
Staffing Problems
Hospitals, the primary employers of RNs (in 2000, 59% of nurses were employed by hospitals),2 traditionally have been the primary providers of acute care. However, over the past 20 years, advances in technology, government cost controls, and the implementation of managed care have shifted patient care from the hospital to alternative settings such as outpatient, home health care, or long-term care settings. Shorter hospitalizations mean that patients who remain hospitalized have higher acuity rates because they are too medically complex to receive care in other settings. Shorter hospitalizations also have implications for nurses in alternative care settings who are subsequently challenged to care for patients with higher acuities than ever before. As a result, employers have changed staffing patterns to accommodate their particular patient populations.
Demand for RNs not only depends on the care needs of an organization's patient population, but also on how providers (ie, hospitals, home health agencies, and nursing homes) use nurses in the care delivery process. For example: when Diagnosis Related Groups (DRG) were introduced in the mid-1980s, hospitals reduced the number of RNs they employed and transferred some RN responsibilities to non-RN personnel. After the introduction of Medicare Prospective Payment Systems (PPS), many providers increased the share of RNs in their workforce.
Unlike shortages in other health professions, the services provided by nurses and nurses aides are hard to replace. Demand for pharmacy services, for example, grows as the number and type of drugs prescribed increases, the population of people receiving them escalates, and the number of pharmacy sites increases. Possibly, some of these pressures and shortfalls could be ameliorated by expanding access to alternative dispensing models such as the Internet or mail-order deliver services. The essential hands-on care provided by nurses and nurse aides is a bit harder to provide through alternative and more "out-of-the-box" designs.
Job Dissatisfaction
Job dissatisfaction has been identified as a major factor contributing to the current problems related to hiring and retaining nurses. The turnover rates for nurses are soaring: they are as high as 26% for hospital nurses, 21% for home care, and 51% in long-term care (nurse aide turnover rates in nursing homes have been reported from 40% to more than 100%).4 High rates of turnover can lead to higher provider costs and more quality-of-care problems, and even may harm patients.
Half of the nurses surveyed by the Federation of Nurses and Health Professionals earlier this year had considered leaving nursing for reasons other than retirement in the last 2 years. Of those who said they were considering leaving, 18% wanted higher wages and 56% said they wanted a less stressful and less physically demanding job.1
Reasons for the Problems
What are the issues contributing to such enormous job dissatisfaction and high turnover rates? Interestingly, higher pay, although it was an issue, was not the primary reason cited. Nurses mentioned inadequate staffing, heavy workloads, the intensity of the work, the increased use of overtime, a lack of sufficient support staff, the lack of respect and recognition they receive from their employers, and inadequate pay as the major drivers of their job dissatisfaction.1
Overtime. The trend toward the use of mandatory overtime as a way of solving staffing issues is currently a major concern of professional nurse associations and unions. Some providers view it as a tool of last resort and a manifestation of the severe shortage of healthcare workers. Others believe that a ban on mandatory overtime would ease the impact of the shrinking nurse supply by encouraging more nurses to stay in the profession. In fact, legislation to restrict the use of mandatory overtime for nurses has been introduced in 10 states. Some senators plan to introduce legislation that calls for financial incentives for healthcare providers that discontinue mandatory overtime and even Medicare penalties for providers that continue the practice.
Pay. In truth, pay has a long-term impact on the size of a workforce pool as well as a short-term effect on people's willingness to work. Pay for RNs lagged behind the rate of inflation between 1994 and 1997. In 2 of the last 3 years, however, RN earnings growth exceeded the rate of inflation.2 The interaction of these two events means the amount a RN can earn today has only just kept pace with the rate of inflation between 1989 and 2000.
More dramatic is the plight of nurse aides (NA). Their low pay, few benefits, and physically demanding and difficult working conditions are linked to a very high turnover rate. Data from the Bureau of Labor Statistics indicates that on average, nurse aides receive lower wages and fewer benefits than workers in general. In 1999, the national average hourly wage for NA was $8.29 in nursing homes, $8.67 in home care, and $8.94 in hospitals. Compare these rates to the average hourly wage of $9.22 for service workers and $15.29 for all workers.4 Nurse aides in home care and nursing homes are more than twice as likely as other workers to receive food stamps and Medicaid benefits and more likely to lack health insurance (one-fourth in home care are uninsured compared to 16% of all other workers).4
Future Needs
Healthcare employment is projected to grow much faster than overall employment, increasing almost 15% between 1998 and 2008. Employment of RNs is expected to grow by almost 22% (794,000 new RNs are needed) and NAs by 58% (567,000 new workers are needed) in the next 7 years.4 The potential mismatch between the future supply of and demand for caregivers is staggering. Impending demographic changes are widening the gap between the numbers of people needing care and those available to provide it. The current high levels of job dissatisfaction among nurses may contribute significantly in determining the extent and depth of this imbalance of supply and demand. Today's nurses, nurse educators, legislators, regulators, and patients of the future have a responsibility to make their voices heard by the authorities that have the power to develop strategies to elicit change.
It is with disease of the mind, as with those of the body; we are half-dead before we understand our disorder, and half cured when we do. - Charles Caleb Colton
1. Federation of Nurses and Health Professionals. The Nursing Shortage: Perspectives from Current Direct Care Nurses and Former Direct Care Nurses (opinion research study conducted by Peter D. Hart Research Associates). Washington, DC: 2001.
