The Truth About Nursing
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Q: What is the nursing shortage and why does it exist?

A: In the most basic sense, the current global nursing shortage is simply a widespread and dangerous lack of skilled nurses who are needed to care for individual patients and the population as a whole. The work of the world's estimated 12 million nurses is not well understood, even by educated members of society. But nursing is a distinct scientific field and autonomous profession whose skilled practitioners save lives and improve patient outcomes every day in a wide variety of settings. In the Truth's view, the vast gap between what skilled nurses really do and what the public thinks they do is a fundamental factor underlying most of the more immediate apparent causes of the shortage. These causes include nurse short-staffing, poor work conditions, inadequate resources for nursing research and education, the aging nursing workforce, expanded career options for women, nursing's predominantly female nature, the increasing complexity of health care and care technology, and the rapidly aging populations in developed nations. Because studies have shown that an inadequate quantity of skilled nurses in clinical settings has a significant negative impact on patient outcomes, including mortality, the nursing shortage is literally taking lives, and impairing the health and wellbeing of many millions of the world's people. It is a global public health crisis. (See The Global Shortage of Registered Nurses: An Overview of Issues and Actions, International Council of Nurses (2004) ("ICN Report").)

In the 1990's, a number of factors combined to produce a nursing shortage in the United States and many other nations in the world. (See ICN Report; Suzanne Gordon, Nursing Against the Odds (2005); Dana Beth Weinberg, Code Green: Money-Driven Hospitals and the Dismantling of Nursing (2003).) During this time in the United States, some nursing positions were actually cut due to the demands of managed care, which had curtailed public and private sector insurance reimbursement rates and placed many hospitals and care facilities in difficult financial positions. Many hospital decision makers, who did not seem to understand or value nursing highly, implemented restructuring plans that had the effect of drastically increasing the workloads of individual registered nurses. Many nurses, who remain sadly underempowered in the current health system, lacked the professional resources to fight effectively against these threats to their patients and themselves. Many tasks formerly performed by nurses--tasks that enabled nurses to perform critical nursing assessments--were now performed by unlicensed assistive personnel, or not performed at all. Short-staffing and restructuring drove away many nurses who could no longer face their growing burnout and/or the realization that they could not meet their professional responsibilities to their patients. By 2005, roughly half a million U.S. registered nurses (about one fifth of the national total) had chosen not to work in nursing. (National Sample Survey of Registered Nurses.)

Meanwhile, U.S. women have come to enjoy a far greater range of career choices than in the past, and men are still not entering nursing in significant numbers. Men comprise only about 6% of working U.S. nurses. At the same time, the nursing workforce is rapidly aging, and too few new nurses are being trained. Poor relations with physicians, including lack of physician respect, physician disruptive behavior and major communication failures, continue to be a problem for nurses, especially where nurses' status is lower. As Suzanne Gordon and others have noted, most women in nursing have not made the gains in workplace empowerment that many of their sisters in other professions have. Even so, in the last few years, interest in nursing has increased to some extent, due to a weak U.S. economy, combined with a growing awareness that nursing offers plentiful, diverse positions with the chance to better lives, and pay that is good relative to the amount of formal training required. Unfortunately, a critical nursing faculty shortage driven by inadequate financial support has hampered efforts to train sufficient numbers of nurses; nursing schools have turned away or waitlisted many qualified applicants. Nursing research receives relatively little funding from the federal government. It comprises a paltry 0.5% of the National Institutes of Health budget (pdf).

The recent increase in interest in nursing in the U.S. has not been sufficient to end the shortage. (See Peter Buerhaus (2004) "Trends: New Signs Of A Strengthening U.S. Nurse Labor Market?") The U.S. continues to face an aging nursing workforce and an explosion in the need for skilled nursing, as the baby boom generation starts to retire, and health care and care technology grow increasingly complex. Legislative efforts to combat the shortage have not yet had a significant impact nationwide. The federal Nurse Reinvestment Act contains promising measures, including incentives to increase the number of nursing faculty, and to the credit of its supporters it has received some funding, though not much relative to other federal programs, and not enough to have a meaningful impact. A number of states have made efforts to address the shortage. California has taken the lead in implementing mandatory nurse staffing ratios that appear to have had a positive impact on patient care and nurse satisfaction, despite fierce and ongoing opposition from the hospital and insurance industries, who argue that specific ratios are impractical and may force hospitals to close. States including Massachusetts and Florida are now considering legislation mandating specific ratios. Recently, bills have also been introduced in Congress to address nurse staffing, including bills to limit mandatory overtime. The SEIU and UNA unions have endorsed bills (currently H.R. 1222) that would establish specific federal nurse-patient ratios. The ANA has recently endorsed a different bill, H.R. 1372, that includes a number of measures designed to improve staffing, but stops short of mandating specific ratios. Instead, it requires that each hospital establish a "staffing system that ensures a number of registered nurses on each shift and in each unit of the hospital to ensure appropriate staffing levels for patient care," based on factors including skill mix, patient acuity, and facility resources. Obviously, the flexibility in this bill could be seen as a way for hospitals to avoid adequate staffing. In any case, despite the above efforts, it is now projected that if current trends continue the United States will be short 275,000 nurses by the year 2010, and that the nation will need to educate about 1.1 million new nurses by 2012--almost half the size of today's nursing workforce. (See US Department of Labor "Occupational employment projections to 2012" (pdf).) If the shortage continues as currently projected, it will have catastrophic effects on the everyday health of the nation and may severely hamper the nation's ability to respond effectively to a mass casualty event.

Globally, the nursing shortage is even more complex, as the November 2004 ICN report makes clear. That important report surveys the causes, nature and effects on patient care of nursing shortages throughout the world. It discusses the "critical challenges" of HIV/AIDS, internal and international nurse migration, and health sector reform and restructuring, and it makes general policy recommendations to address these critical problems. One of the most alarming trends discussed in the report (and many current news reports) is the migration of many of the most skilled developing world nurses to much better paying positions in developed nations with shortages, with a devastating impact on already overburdened health systems in the poorer nations. The report notes that the nurse:population ratio varies greatly in different nations. The average ratio in Europe is 10 times that in Africa and South East Asia, and one recent estimate is that sub-Saharan Africa is currently short over 600,000 nurses needed to meet Millennium Development Goals. Some nations, particularly in Central and South America, actually have more physicians than nurses (in the U.S., there are about 700,000 physicians and 2.9 million registered nurses). Many nations also reportedly suffer from a poor distribution of nurses, with few nurses available in rural and remote areas. The ICN report stresses the considerable research showing the link between nurse staffing levels and positive care outcomes. (See ICN Report at 4-6.) In explaining the shortage, it notes that "[g]ender-based discrimination continues in many countries and cultures, with nursing being undervalued or downgraded as 'women's work.'" (Id. at 5.) The report concludes that "[w]ithout effective and sustained interventions, global shortages will persist, undermining attempts to improve care outcomes and the health of nations." (Id. at 6.)

Analytically, what is called the "nursing shortage" can be viewed as operating in several different--though related and overlapping--ways. Of course, the shortage at its simplest is a lack of adequate numbers of skilled practicing nurses, as seen now in most nations of the world. However, it may be useful to think more specifically about the exact nature of what the world is "short" of. Below are some suggestions.

The nursing shortage: What are we short of?

A "willing nurse" shortage

A funding or perceived funding shortage

A shortage of understanding that nurses are needed to deliver care

A nurse education and empowerment shortage

A "willing nurse" shortage

One type of nursing shortage is the simple lack of nurses to fill open, funded job vacancies, as many nations are now experiencing. The most obvious evidence of this is numerous nursing job vacancies. This kind of shortage may occur because the needed nurses do not exist, or because many existing nurses are not willing to provide care in the prevailing care environment, as is currently the case in many parts of the United States due to short-staffing and other factors. In this sense, the current shortage may be described as being, at least in part, a "willing nurse" shortage.

A funding or perceived funding shortage

A second type of shortage may occur where there is a lack or perceived lack of funds to finance nursing positions that are generally understood to be needed. For instance, a given facility decision-maker may understand that a particular unit shift really needs five nurses, but have the funds for only three positions. This is the classic short-staffing scenario seen in the United States since the 1990's. It may be described as more of a "nursing" shortage, in the sense that nurses may be available and willing to work, but there do not exist the funds (or the will to expend the funds) to pay for them.

As an indication of the depth of underfunding of nursing, a 2007 report on the 32,000 U.S. nurse educators by the National League for Nursing and the Carnegie Foundation found that nurse educators earn only three-fourths of what faculty in other academic disciplines earn. They also earn only $3 out of every $5 of that earned by nurse anesthetists and "significantly less than nurse administrators, consultants, supervisors, head nurses, nurse practitioners and midwives with the same educational credentials."

A shortage of understanding that nurses are needed to deliver care

A third type of shortage may occur where there is a lack of general agreement or awareness that nursing is even needed to care for a given patient population. Once again, the current situation in the United States may to some extent reflect this type of shortage, since recent hospital restructuring has often entailed nurse short-staffing that seems to reflect a lack of awareness on the part of some decision-makers that an adequate quantity of skilled nursing is needed. As noted above, in many facilities tasks formerly performed by nurses have in recent years been assigned to less highly trained assistive personnel, with serious effects on patient outcomes. This type of shortage may be even more obvious in nations where relatively few nurses exist. In some nations, physicians reportedly may provide some of the monitoring and other care that nurses provide in nations like the United States. Moreover, in some developing nations, less skilled care givers and patients' families may provide some of the custodial care that nurses in developed nations provide or direct. However, to the extent patients are not receiving the science-based therapeutic care that skilled registered nurses provide, patient outcomes will reflect the lack of such care. This is also a "nursing" shortage, though addressing it will require more than mere financial action. Instead, what is needed is a basic change in the way a society, particularly its decision-makers, actually think about nursing and health care generally. If the type of nurse:population ratio seen in the most developed nations--roughly 1:100--were to be seen throughout the world, it could require something like 50 million additional nurses.

A nurse education and empowerment shortage

Finally, it might be argued that a fourth type of shortage occurs where nurses do staff nursing positions in numbers that should be sufficient to provide care, but many of the nurses have not received sufficient training and social empowerment to provide high quality care. Research has associated nursing staff who have more formal education and better work environments with significantly better patient outcomes. This lack of nursing empowerment may be a problem in any nation or setting, though it may be more obvious in areas where training resources are scarce and social attitudes may inhibit nurses from advocating for their patients or themselves.

In the Truth's view, a critical factor that underlies most of the above facets of the current nursing shortage is the huge gap between the actual nature and value of nursing, on the one hand, and what policymakers, career seekers and the public at large believe about the profession on the other. Because nursing continues to be regarded as a peripheral, menial job for women with few other options, it has not received adequate resources or respect. Short-term financial infusions such as scholarships and loan forgiveness, though helpful, will not fix this deeper problem. Because studies have shown that the media has a significant impact on health-related views and actions, nursing's generally poor, inaccurate media image is a major factor in the current crisis. The Truth believes that the global nursing shortage cannot be resolved until public understanding of nursing dramatically improves. (See Gordon, Nursing Against the Odds.)

last updated: October 18, 2007

Also see a nursing shortage fact sheet from the American Association of Colleges of Nursing.

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