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Throughout the history of nursing in the United States, there have been swings of shortage and oversupply of registered nurses, reflecting changes in demand for nursing services, the growth or decline of hospitals and health funding, changing perceptions of nursing as a profession, and widening career opportunities for women.
Today, nursing is again in a period of significant change, and recent surveys suggest that some hospitals are having difficulty recruiting registered nurses, particularly experienced, specialty-trained nurses. In the “Nursing Shortage Study,” conducted in 1998 by the Hay Group, a health care consulting firm that surveyed 178 hospitals, 94% of respondents from the Western U.S. indicated that they either have or anticipate a shortage, followed by the Northeast region at 82%. The Midwest region was last, with 75% of respondents experiencing or predicting a shortage. Overall, 81% of the respondents indicated that they have or anticipate a shortage of nursing middle managers, registered nurses, licensed practical nurses, and unlicensed assistants. Registered nurse respondents ranked insufficient staff, turnover, patient acuity increases, a dearth of new graduates, and patient volume increases as the “most likely reasons for the current or anticipated shortage.”
Recognizing that these issues must not be addressed in isolation, the ANA hosted a symposium in March called “Predicting the Need for Nursing Services in a Changing Health Care System: What We Can Achieve Through Forecasting.” Economists, forecasters, health service researchers, nursing specialty organizations and representatives of state nurses associations representatives convened and reviewed existing data on nursing supply and demand, examined multidisciplinary approaches to workforce planning, and discussed local and regional strategies for averting a shortage.
According to a 1996 national sample survey, there are 2.6 million registered nurses in the United States, of whom 2.1 million are employed in actual practice. The majority—60%—work in hospitals, and the remainder practice in community or public health care settings, ambulatory care settings, nursing homes, and other extended care facilities. Currently, 27% of registered nurses hold a diploma as their highest nursing credential; 32% hold an associate’s degree; 31% hold a baccalaureate degree; 9.1% hold a master’s degree; and 0.6% hold a doctorate.
Two factors that will greatly influence the future supply of RNs are the aging of the nursing population as a whole, and the aging of the nursing faculty. In 1996, the average age of all registered nurses was 44.3 years, and the average age of employed nurses was 42.3 years. And in the fall of 1997, the average age of nursing faculty in bachelor’s and graduate degree programs was 52.1 and 48.5 years, respectively. Doctoral students are older on average, too: In 1996, the average age of a new doctoral recipient in nursing was 45 years, almost 12 years older than the average age of doctoral recipients in all other fields.
And enrollment in master’s degree programs for nurse educators is declining. In 1997, only 4% of master’s degree students chose to pursue a career in teaching, down from 7.5% in 1995. This is partly due to the increasing preference for advanced practice curricula, which rose from 42% of master’s enrollments in nursing schools in 1996 to 57% in 1997.
While there are many influences on the demand for nursing services, three are particularly significant: reorganization of the health care system, changes in demographics, and new technologies.
Trends that affect the demand for nursing services include the emphasis on cost containment and on increasing competition in health care; hospital consolidations, downsizing, and re-engineering; reductions in inpatient hospitalization rates; higher acuity of hospital patients; and a greater focus on primary care and health promotion.
Another significant trend affecting the demand for nurses is the aging of the United States population, particularly as the number of people 85 years old and older increases. The Institute of Medicine’s 1996 report, “Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?” concludes that aging and the consequent increase in chronic illness will augment the demand for nurses—particularly those with baccalaureate or master’s degrees—in both hospitals and nursing homes.
And technologic advances are likely to prolong the lives of the chronically ill, consequently increasing the demand for long-term nursing care.
A number of researchers are predicting which forces will most affect nursing services. While these projections vary in focus and scope, most maintain that the demand for specialty-trained registered nurses is increasing, and that the supply of nurses is unlikely to keep pace. In 1991, for example, the Division of Nursing at the Department of Health and Human Services predicted that the supply of nurses will continue to increase until the year 2010, but only marginally between 2000 and 2010. The organization expects that supply will decline thereafter.
In 1998, registered nurse and researcher Peter Buerhaus predicted a significant shortage of RNs beginning around 2007. Buerhaus foresees a rising demand resulting from such factors as an aging population, the longevity of the chronically ill, technologic advances, the growing prevalence of antibiotic-resistant infections, cost-cutting pressures imposed by managed care, the shift from high-cost acute care facilities to lower-cost ambulatory and community settings, and increased attention to quality improvement. But such forces as the rising age of the nursing workforce, falling participation rates in the workforce, declining enrollment in BSN programs, nursing’s failure to attract male and minority students, and the uncertainty about income potentials threaten the supply of nurses. Buerhaus predicts that in the next five to 10 years the number of nurses withdrawing from the labor market will exceed the number of new entrants. Thus, demand will outpace supply.
A study conducted by Edward Salsberg and company in 1998, called “Strategies for the Future of Nursing: Changing Roles, Responsibilities, and Employment Patterns of Registered Nurses,” predicts a 50% to 75% increase in the demand for advanced practice registered nurses (APRNs) in the next decade; a 10% decrease in the demand for registered nurses without APRN preparation in the next 10 to 15 years (because of job attrition in inpatient facilities that won’t be completely offset by the increase in job opportunities in nonhospital settings); and a long-term risk of a nursing shortage resulting from lags in the response of the labor supply, potential sharp reductions in nurse education subsidies, and decreased participation of an aging workforce.
The ANA believes that the dramatic swings in the supply and demand of registered nurses have a negative impact on patient care, harm the nursing profession, and are costly to the health care industry. The resounding consensual opinion of the experts attending the March symposium asserted that nursing can no longer afford to engage in workforce planning in isolation. The integration of health services and the changing scopes of practice demand that all health professions develop multidisciplinary planning that includes forecasting models (formulas designed to predict future trends) flexible enough to work at the local, state, and national levels.
To ensure that nursing plays an active role in this effort, the House of Delegates, at its June meeting, considered whether the ANA should push for the development of integrated forecasting models at all levels as well as strategies that address the impact of an aging workforce. The House also discussed ANA collaboration with groups such as the American Organization of Nurse Executives (AONE) and with state nurses associations on strategies to retain experienced nurses and to ensure appropriate numbers of adequately prepared nursing faculty. (For a full report, see The American Nurse, July–August 1999.)
American Association of Colleges of Nursing. 1998–1999 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing. Washington, DC: The Association, 1999.
American Association of Colleges of Nursing. 1997–1998 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing. Washington, DC: The Association, 1999.
American Association of Colleges of Nursing. As RNs age, nursing schools seek to expand the pool of younger faculty. AACN Issue Bull, June 1998. Available online <http://www.aacn. nche.edu/Publications/issues/JUN98.htm>, accessed May 14, 1999.
Buerhaus, P. I. Is another RN shortage looming? Nurse Outlook 46(3):103–108, 1998.
Division of Nursing Health Resources and Services Administration. Health Personnel in the United States: Eighth Report to Congress. Washington, DC: U.S. Department of Health and Human Services, 1991.
The Hay Group. 1998 Nursing Shortage Study. Walnut Creek, CA: The Group, 1999.
Moses, E. B. The Registered Nurse Population: March 1996, Findings from the National Sample Survey of Registered Nurses. Rockville, MD: U.S. Department of Health and Human Services, [1996].
Salsberg, E., et al. Projecting the Future Supply and Demand for Registered Nurses. Strategies for the Future of Nursing: Changing Roles, Responsibilities, and Employment Patterns of Registered Nurses. San Francisco: Jossey-Bass, 1998.
U.S. Institute of Medicine. Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes. Nursing Staff in Hospitals and Nursing Homes: Is it Adequate?, edited by C. S. Wunderlich, et al. Washington, DC: National Academy Press, 1996.