Sponsored Listings
Questia: Search over 400,000 books and journals at Questia online.
FastWeb
Free Scholarship Search: Find free
money for college or an advanced degree.
General
Accounting Office
Excerpts from Nursing Workforce: Recruitment and Retention of Nurses and
Nurse Aides Is a Growing Concern
May 17, 2001
Nursing Shortages: A Growing Concern
Recruitment
and retention of both nurses and nurse aides are major concerns for health
care providers. Experts and providers are reporting a current shortage of
nurses, partly as a result of patients’ increasingly complex care needs.
While comprehensive data are lacking on the nature and extent of the
shortage, it is expected to become more serious in the future as the aging
of the population substantially increases the demand for nurses. Moreover,
several factors are combining to constrain the current and future supply
of nurses. Like the general population, the nurse workforce is aging, and
the average age of a registered nurse (RN) increased from 37 years in 1983
to 42 in 1998. Enrollments in nursing programs have declined over the past
5 years, shrinking the pool of new workers to replace those who are
retiring. In addition, numerous studies report decreased levels of job
satisfaction among nurses, potentially leading to their pursuing other
occupations.
Demographic
changes over the coming decades may also worsen the shortage of nurse
aides in hospitals, nursing homes, and home health care settings. With the
aging of the population, demand for nurse aides is expected to grow
dramatically, while the supply of workers who have traditionally filled
these jobs will remain virtually unchanged. According to the Institute of
Medicine (IOM), advocacy groups, and provider associations, a serious
shortage of nurse aides already exists. Retention of nurse aides is a
significant problem for many providers, with some studies reporting annual
turnover rates for aides working in nursing homes approaching 100 percent.
Several factors contribute to providers’ difficulty in both hiring and
retaining nurse aides, including relatively low wages and few benefits. In
addition, research has found that the physical demands of the work and
other aspects of the workplace environment lead to difficulties in
retaining nurse aides. In 1999, 30 states indicated that they were
addressing nurse aide recruitment and retention through task forces,
initiatives, and research. The federal government and provider groups also
have begun to address this issue. However, few studies have evaluated the
effectiveness of these efforts.
Background
RNs
and licensed practical nurses (LPN) are responsible for a large portion of
the health care provided in this country. RNs make up the largest group of
health care providers, and, historically, have worked predominantly in
hospitals; a smaller number of RNs work in other settings such as
ambulatory care, home health care, and nursing homes. (See table 1.) Their
responsibilities may include providing direct patient care in a hospital
or a home health care setting, managing and directing complex nursing care
in an intensive care unit, or supervising the provision of long-term care
in a nursing home. LPNs make up the second-largest group of licensed
health caregivers and primarily provide direct patient care under the
direction of a physician or RN. Nurse aides augment the care nurses
provide by performing routine duties of caring for hospital patients or
long-term care residents under the direction of an RN or LPN. Most nurse
aides work in nursing homes, where they provide assistance with activities
of daily living such as dressing, feeding, and bathing.
Both
RNs and LPNs are subject to state licensing requirements. Individuals
usually select one of three ways to become an RN—through a 2-year
associate degree, 3-year diploma, or 4-year baccalaureate degree program.
LPN programs are 12 to 18 months in length and generally focus on basic
nursing skills such as monitoring patient or resident condition and
administering treatments and medications. Federal law requires states to
certify nurse aides who provide care in nursing homes and for home health
care agencies that receive Medicare and Medicaid reimbursement.
This certification can be
obtained through either a nurse aide training program and a competency
evaluation—a written or oral test and skills demonstration—or
competency evaluation alone. A state-approved nurse aide training program
must require a minimum of 75 hours of training, including at least 16
hours of supervised practical training under the direct supervision of an
RN or LPN. Approximately half of the states require the nursing aide
training programs to go beyond the 75-hour minimum, with several requiring
over 120 hours. Federal
law also requires states to maintain a registry of nurse aides working in
nursing homes who have passed their competency evaluations; no such
requirement exists for aides working in home health care.
For nurse aides working in
hospitals, there are no federal requirements related to certification,
training, competency evaluations, or a registry.
Demographic
and Job Satisfaction Factors Could Worsen Shortage of Nurses
The
nation’s health care providers are reporting a shortage of nurses in a
range of settings. Although comprehensive data are lacking to describe the
nature and extent of the current shortage, there is evidence of a growing
demand for nurses with skills to treat patients with complex care needs.
Furthermore, shortages can affect the quality of care. The shortage is
expected to worsen as the aging population increases demand and fewer
people enter the nurse workforce. Job dissatisfaction among nurses may
further reduce the strength of the nursing supply.
Providers
and experts around the country have reported that the nation is currently
facing a shortage of nurses. There is a lack of comprehensive national
data to describe the full nature and extent of the shortage, but several
types of information point to an existing shortage. For example,
California reported an RN vacancy rate of 8.5 percent for all employers in
1997, with hospitals reporting a rate of 9.6 percent, nursing homes 6.9
percent, and home health care 6.4 percent. The Dallas-Fort Worth Hospital
Council reported vacancy rates for 2000 of 9.3 percent for RNs in
emergency departments and 16.9 percent for RNs in critical care units. A
recent survey of providers in Vermont found that nursing homes and home
health care agencies had RN vacancy rates of 15.9 percent and 9.8 percent,
respectively, while hospitals had an RN vacancy rate of 4.8 percent (up
from 1.2 percent in 1996).
An
important factor in the current shortage is the higher proportion of
patients having more complex care needs, which increases the demand for
nurses with training for specialty areas such as critical care and
emergency departments. In addition, the increased use of technology in
care settings has increased the demand for a higher skill mix of RNs.
Furthermore, the expansion of care delivery settings—such as home health
care and community-based health care delivery systems—has increased the
job opportunities available and demand for these workers.
A
nursing shortage may have serious implications for the quality of patient
care. A recent HRSA study found a relationship between higher RN staffing
levels and the reduction of certain negative hospital inpatient outcomes,
such as urinary tract infection and pneumonia. Furthermore,
a recent Health Care Financing Administration (HCFA) report to Congress
found a direct relationship between nurse staffing levels in nursing homes
and the quality of resident care. HCFA’s analysis of three states’
data demonstrated that, after controlling for case mix, there is a minimum
nurse staffing threshold below which quality of care may be seriously
impaired. 6 However,
23 percent of the facilities in the three states were not staffing at the
combined RN and LPN minimum staffing threshold level, and 31 percent of
the facilities were not staffing at the RN minimum staffing threshold
level.
The
Nursing Shortage Is Likely to Worsen
The
nursing shortage is expected to worsen in the future, with pressures
expected on both demand and supply. The future demand for nurses is
expected to increase dramatically when the baby boomers reach their 60s,
70s, and beyond. The population aged 65 years and older will double from
2000 to 2030. Moreover, the population aged 85 and older is the fastest
growing age group in the U.S. At the same time, the number of persons who
have traditionally worked in the nursing workforce—women between 25 and
54 years of age—is expected to remain relatively unchanged over the
period from 2000 to 2030.
Over
the past decade, the nurse workforce’s average age has climbed steadily,
while fewer young persons are choosing to enter the nursing profession.
The average age of the RN population in 2000 was 45, almost 1 year older
than the average in 1996. While over half (52 percent) of all RNs were
reported to be under the age of 40 in 1980, fewer than one in three were
younger than 40 in 2000. During the same period, the percentage of nurses
under age 30 dropped from 25 to 9 percent. As shown in figure 1, the age
distribution of RNs has shifted dramatically upward. The number of nurses
aged 25 to 29 decreased from about 296,000 in 1980 to about 177,000 in
2000, while the number aged 45 to 49 grew from about 153,000 to about
465,000.
The
total number of licensed RNs increased 5.4 percent between 1996 and
2000—the lowest increase ever reported in HRSA’s periodic survey of
RNs. Nursing
program enrollments further indicate a narrowing of the pipeline.
According to a 1999 Nursing Executive Center Report, between 1993 and
1996, enrollment in diploma programs dropped 42 percent and enrollment in
associate degree programs declined 11 percent. Furthermore, between 1995
and 1998, enrollment in baccalaureate programs declined 19 percent, and
enrollment in master’s programs decreased 4 percent. Over the past 25
years, career opportunities available to women have expanded
significantly, while there has been a corresponding decline of interest by
women in nursing as a career. A recent study reported that women
graduating from high school in the 1990s were 35 percent less likely to
become RNs than women who graduated in the 1970s.
In
addition to the lack of students entering and graduating from nursing
programs, there is concern about a pending shortage of nurse educators.
The average age of professors in nursing programs is 52 years old, and 49
years old for associate professors. The average age of new doctoral
recipients in nursing is 45, compared with 34 in all fields. From 1995 to
1999, enrollments in doctoral nursing programs were relatively stagnant.
Demographic
changes over the coming decades may also worsen the shortage of nurse
aides. With the aging of the population, demand for nurse aides is
expected to grow dramatically, while the number of persons who have
traditionally filled these jobs will change very little. Retention of
nurse aides is currently a significant problem for many hospitals, nursing
homes, and home health care agencies, with some studies reporting annual
turnover rates for aides working in nursing homes approaching 100 percent.
Low wages, few benefits, and difficult working conditions contribute to
recruitment and retention problems for nurse aides. High turnover can
contribute to both increased costs to the facility and problems with
quality of care.
Concluding
Observations
Recruitment and retention of nursing staff—both nurses and nurse aides— pose a problem today that will likely worsen as demand for these workers increases in the future. Demographic forces are widening the gap between the numbers of people needing care and the nursing staff available to provide care. As a result, the nation will face a shortage of different dimensions than those of the past. The private sector and state governments have taken the lead in trying to address recruitment and retention issues for nurse aides. Additional evaluation is needed to determine which initiatives are most effective. More detailed data are also needed to delineate the extent and nature of nurse and nurse aide shortages to assist in planning and targeting corrective efforts. As the federal government focuses more on the nursing workforce in hospitals, nursing homes, and home health care, support for the evaluation of efforts to increase the supply of nurses and nurse aides may also help identify more effective steps to ameliorate the shortage.
This document is not necessarily endorsed by the Almanac of Policy Issues. It is being preserved in the Policy Archive for historic reasons.