A Nursing Shortage in an Increasingly Complex Healthcare Environment
Significant advances in biomedical science and in the complexity of health care, coupled with a worsening
nursing shortage and numerous reports of unsafe and inadequate patient care, are challenging both
nursing education and nursing practice to look for innovative approaches to increase and maintain a
qualified and competent nursing workforce (Health Care’s Human Crisis:The American Nursing Shortage,
Kimball, 2002; Cultural Transformation in Healthcare, Kimball, 2005; Long, 2004; Designing the 21st
Century Hospital, Robert Wood Johnson Foundation, 2005).
A number of nursing shortages have occurred in the past. However, as Berliner and Ginzberg (2002)
point out previous nursing shortages resulted from a mismatch between the demands of the market and
the difficulties healthcare organizations encountered in raising wages and the willingness of new
graduates to work for those wages. Today’s nursing workforce problems are more complex and driven by
fundamental demographic changes. Of these, there are three separate, but related, demographic
changes occurring; a decline in the number of new nurses entering the workforce, high turnover (55% to
61%) rates of new nurses changing jobs, and an aging nursing workforce that is retiring or leaving the
workforce early (Casey et al., 2004; Roche et al., 2004).
These shifts are happening at a time when the population is aging and the demand in all sectors of
healthcare is increasing. The 76 million strong baby-boom generation now ranges in age from 40 to 59,
and already shows signs of stressing the resources of our healthcare system. Over the next thirty years,
this generation will require significant amounts of healthcare for chronic diseases (such as cardiovascular diseases and stroke; diabetes; respiratory diseases; cancer), acute illnesses (heart attack), and end-oflife
care. In addition, the chronic disease burden, and need for care, is increasing for people of all ages.
Changes in the approach to the delivery of healthcare are impacting nursing demand. Many conditions
that required hospitalization in the past are treated in the ambulatory care setting. Consequently, people
admitted to hospitals today are much sicker than people in hospitals fifteen years ago; their care is
technology intensive, complex and demanding. People are discharged from hospitals when they are still
very ill, with recovery occurring in nursing homes or at home.
Nationally, registered nurses (RNs) are the largest licensed healthcare professional group with 83.2
percent (an estimated 2,421,461 RNs) employed in 2004 (Health Resources and Services Administration,
2004). The number of RNs with an associate degree increased from 19 percent (308,616 nurses) in 1980
to 42.2 percent (1,227,256) of the workforce in 2004. For RNs who completed their initial education in a
baccalaureate degree program, the estimated figures indicate an increase from 17.3 percent (287,993) in
1980 to 30.5 percent (887,223) in 2004. In addition, an estimated 0.5 percent of RNs in 2004 (15,511)
had received their initial nursing education through a master’s or doctoral degree program (Health
Resources and Services Administration, 2004).
The supply of nurses is dependent upon the number of new nursing graduates entering the profession,
and the number of existing nurses remaining in the profession. While over 92% of registered nurses are
women the increase in occupations open to women has resulted in both fewer young women entering
nursing than in the past, and many nurses leaving the profession for career opportunities that are less
physically / emotionally demanding and provide better salaries. The result is a declining supply of nurses
in the United States. In March 2004, the National Sample Survey of Registered Nurses (NSSRN) identifies that the national average age of the registered nurse population was estimated to be 46.8 years,
more than 4 years greater than in 1996 when the average age was 42.3 years (Health Resources and
Services Administration, 2004). Those who educate new nurses, nursing faculty, have an average age of
46.8, but more concerning is that the highest educated nurses, those with doctorates in nursing or related
fields average 55.7 years (Health Resources and Services Administration, 2004) Even if there is an
increase in the number of young people seeking to become nurses, we cannot increase current
production without increasing nursing faculty.
The Association of American Colleges of Nursing (AACN) 2003 white paper “Faculty Shortages in
Baccalaureate and Graduate Nursing Programs: Scope of the Problem and Strategies for Expanding the
Supply” reports that according to projections from the Bureau of Labor Statistics (BLS), there will be more
than one million vacant positions for RNs by 2010 due to growth in demand for nursing care and net
replacements due to retirement (Hecker, 2001). Data from the 2000 National Sample Survey of
Registered Nurses (NSSRN) estimated that 39 percent of RNs employed in nursing held baccalaureate or
master's degrees in nursing (Spratley, Johnson, Sochalski, et al., 2001). The 2004 NSSRN Survey indicates these estimates have risen slightly to 41 percent. Therefore, one can postulate that at least
410,000 of the vacancies projected by the BLS will be for RNs with baccalaureate or master's nursing
degrees, which translates into the need for large numbers of well-prepared faculty to educate these new
nurses. In addition, US high schools will graduate the largest class in history in 2007-2008 a projected 3.2
million graduates (Western Interstate Commission for Higher Education, 1998). Even if enrollment
demand in nursing increases only modestly, will sufficient numbers of nursing faculty be available to
teach these students?
Hawaii’s Healthcare Industry & Nursing Workforce Shortage
Hawaii’s healthcare industry is the second largest private industry and the health services sector (i.e.,
providers, clinics, hospitals, and nursing facilities) provided more than $3 billion toward the state gross
product in 2003 (Healthcare Association of Hawaii, 2005). Healthcare Association of Hawaii (HAH) identifies that Hawaii's healthcare industry employed more than 40,000 individuals in 2003 and paid out more than $1.6 billion in wages. Out of those employed, registered nurses (RNs) make up the largest
licensed healthcare professional group. ‘Hawaii’s Health in the Balance: A Report on the State of the
Nursing Workforce’ identifies there is currently an estimated shortfall of 1,518 RNs in Hawaii (Raynor et
al. 2004). This shortfall is projected to rise to 2,267 RNs by 2010. Employer demand for RNs between
2002 and 2012 is expected to increase by 24 percent. However, the supply of RNs is expected to grow
only by about 10 percent and by 2012, 3,500 registered nurses will be required to fill new positions (53%
of job openings) and replace those RNs retiring (47% of job openings) (Hawaii Department of Labor and
Industrial Relations, 2006). In 2003, nursing programs graduated a total of 330 students and forecasts
indicate if graduation rates do not increase dramatically there will not be enough new graduates to
replace retiring nurses and meet the growing employer demand.
As the gap widens between supply and demand of RNs, employers will find it increasingly difficult to fill
vacant positions and some positions will remain vacant for extended periods. As seen in other healthcare
delivery settings across the country where positions remain vacant the employer response may be to
continue to provide services with fewer RNs threatening the quality of care and/or reducing access to
care by delaying or discontinuing services. Thus, the growing nursing shortage is expected to have a
significant negative impact not only on our local population requiring healthcare services but also on
people from Asian and Pacific Rim countries coming to Hawaii expecting to receive the most
contemporary medical treatments, restorative and rehabilitative care, procedures and services.
Hawaii’s Efforts to Address the Nursing Workforce Shortage: A Catalyst Bringing Together Education & Practice
In 2003, the Hawaii State Legislature established the Hawaii State Center for Nursing (HCSFN) (Act 198,
HB 422) in an effort to address the nursing shortage. The Center is one of a number of State Nursing
Workforce Centers (Michigan Center for Nursing, New Jersey Collaborating Center for Nursing, North
Carolina Center for Nursing, Oregon Center for Nursing, Tennessee Center for Nursing, Inc., Washington
Center for Nursing, New Mexico Center for Nursing Excellence, and Mississippi Office of Nursing
Workforce) that serves as a catalyst for the implementation of innovative education and practice models
by bringing together individuals at the state and local levels, nursing leaders, educators and healthcare
organizations to strategically address nursing workforce issues at the grass roots level (see Robert Wood
Johnson Foundation Charting Nursing’s Future, Nov. 2005).
The Center’s efforts build upon previous work begun in 1996 when Hawaii was one of 20 sites nationwide
to receive funding from the Robert Wood Johnson Foundation for the initiative, ‘Community Initiative on
Nursing in Hawaii’ (CINH) and has resulted in ongoing work to forecast the supply of nurses for our state.
The efforts of the many individuals involved in the work of CINH have resulted in a solid foundation for the
Center which is positioned to become a powerful catalyst for change. The functions of the Center include
collect, analyze data, prepare, and disseminate written reports and recommendations regarding the
current and future status and trends of the nursing workforce; conduct research on best practices and
quality outcomes; develop plans for implementing strategies to recruit and retain nurses; and research,
analyze, and report data related to the retention of the nursing workforce.
As the hub of statewide strategic planning and data collection, the Center supports proactive workforce
planning; fosters recruitment initiatives; and evaluates and disseminates strategies that will lead to higher
levels of job satisfaction and improved retention among nurses. The Center will build coalitions across the
broad spectrum of stakeholders in our state and will facilitate the efforts of the many individuals and
groups already involved. |
