Combatting the Nursing Shortage, Part 1

Since the 1990s, American and Canadian hospitals have been struggling with a shortage of nurses. According to information from the American Association of Colleges of Nursing (AACN), the average nurse vacancy rate in US hospitals was 13% in 2002, and more than one in seven hospitals reported an RN vacancy rate of 20% or more.

The problem has reached crisis proportions, and shows no sign of abating. The Baby Boom generation is aging, and will soon be placing unprecedented demands on the healthcare system. Nurses themselves are also aging. The 2004 National Sample Survey of Registered Nurses found that the average age of American RNs was 46.8 years. Between 1995 and 2003, the National Council of State Boards of Nursing reported a 20% decline in the number of nursing graduates sitting their national licensure exam, indicating that there likely will not be enough new nurses to replace the ones who retire. Employment projections from the US Bureau of Labor Statistics indicate that more than one million new and replacement nurses will be needed by 2012.

In Canada, according to the Canadian Nurses Association's 2005 Workforce Profile of Registered Nurses in Canada, the average age of a Canadian RN was 44.7 years. And the Canadian Institute for Health Information's report Workforce Trends of Registered Nurses in Canada, 2005 noted that in 2005, there were 251,675 RNs employed as nurses, and of these RNs, 19.7% were 55 or older, thus a large pool of Canadian RNs are nearing typical retirement age.

The nursing shortage is a complex challenges with many causes. Here is a look at some of the problems that have driven nurses away from the bedside, and some solutions that may help bring them back.

Where to Find the Nurses?

New RNs are desperately needed to fill current vacancies and the future demands of the Baby Boom generation. However, the nursing shortage is also taking its toll on nursing schools. The National League of Nursing estimated that 147,000 qualified applicants were turned away from nursing schools in 2005 due to lack of space. A shortage of nursing instructors, and the imminent retirement of current faculty, is a large part of this problem.

The 2004 National Sample Survey of RNs noted that, in the United States, the estimated average age of faculty nurses with doctorates in nursing or a related field was 55.7 years. And in Canada, the Registered Nursing Education in Canada: 2004 Snapshot (updated in 2006) reported that the average age of RN faculty in Canada is 47.6 years, while in the administrative area of nurse education, the average age was 49.4 years. However, the Canadian snapshot also noted, "Faculty retirement projections considered in conjunction with current staffing challenges indicate a need for 3,673 Master's-prepared nurses annually" – and in 2004, there were 418 only Master's graduates and 25 doctoral graduates.

Innovative programs, such as faculty sharing among nursing schools, and more fast-track RN training programs for individuals who already hold Bachelor's degrees in other fields, can help alleviate the problem. More funding for student places and tuition aid will also help bolster enrollment. The 2002 US Nursing Reinvestment Act is definitely a step in the right direction, and offers nursing scholarships, grants, loan cancellations, and other financial support for nurses in training.

Nursing schools can also work to attract a more diverse student population. The 2004 American national sample survey of RNs estimated that 94% of RNs were women, and 82% were white, while Canadian numbers from 2005 showed that 94.4% of the nursing population was female.

Aggressively recruiting RNs from abroad can also help fill some vacancies in North American hospitals. The same survey estimated that 3.5%, or 100,791 of the RNs practicing in the United States received their basic nursing education outside the United States, while Canadian numbers from 2005 show that 7.6% of nurses were internationally educated. However, this strategy poses an ethical dilemma, in that it deprives the nurses' home countries of needed medical personnel.

Reentry nurses can also be an extremely valuable resource. The document entitled "The Registered Nurse Population: National Sample Survey of Registered Nurses March 2004" by the US Department of Health and Human Services found that 16.8% of RNs were not actually working in nursing. For those who wish to reenter clinical practice, hospitals and nursing schools can offer courses to update nurses on current technology and procedures. Hospitals can attract reentry nurses by offering orientation programs that are geared to the hospitals' needs, as well as flexible schedules and a graduated level of responsibility that increases as the nurses become reacclimatized to clinical practice.

Retaining Nurses

Although there is a lot of focus on recruitment, the best and most cost-effective way for hospitals to staff their units is to hold on to the nurses they already have. In Where Have All the Nurses Gone?, author and RN Faye Satterly states that the estimated cost of replacing an RN is 80-100% of the nurse's first year salary. For hospitals that employ hundreds of RNs and have a high turnover rate, this could translate into millions of lost dollars each year.

Today's nurses can choose from careers in many settings, including home health, research, pharmaceutical sales, legal nurse consulting, and more. To prevent nurses from leaving the bedside for other jobs with good (or better) pay and better hours, hospitals must work hard to improve working conditions and make themselves into more attractive employers for nurses.

Competitive Compensation

In Where Have All the Nurses Gone?, Satterly reports that some hospitals have resorted to "bidding wars." While high salaries and generous signing bonuses can certainly attract new employees, they cannot prevent nurses from leaving due to poor working conditions or being lured away by a better offer elsewhere. Indeed, a 2005 review entitled Nurse Retention and Recruitment: Developing a Motivated Workforce by the International Council of Nursing reported that an increase in wages will not lead to a substantial increase in labor population. If anything, increased wages will help with nurse retention in developing countries, but not developed countries.

Satterly found that nurses were interested not only in monetary figures, but also wanted their salaries to reflect their level of responsibility, and as proof that their work was valued by hospital management. Besides higher salaries, monetary incentives can also include pension plans, employee anniversary bonuses, and programs to help repay student loans, fund additional education, or fund nursing training in exchange for a period of service at a hospital.

But compensation can also include non-monetary incentives. Achieving balance between their professional and personal lives is a key concern for many nurses. Hospitals can help by offering flexible schedules, along with onsite fitness classes, peer support groups, and other wellness programs.

Employers should also offer compensation based on what may be important to nurses at different stages of their lives. Since more than 90% of RNs are women, better maternity benefits and onsite childcare can make an employer much more attractive to a younger nurse. But considering that the average age of American and Canadian nurses is in the mid-40s, employers should also offer pension incentives, more time off, flex-time to care for aging parents, and other benefits that would be useful to a nurse nearing the end of her or his career.

In short, good wages alone are not enough to guarantee long-term loyalty. Instead, a competitive compensation package should be part of a reward system that recognizes nurses' accomplishments and responds to their needs.

Next week, see Combatting the Nursing Shortage, Part 2.

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