The Nursing Shortage Karin Mogren-Kuzma This seminar will discuss the nursing shortage. I hope you will enjoy this presentation! /Karin The Nursing Shortage Karin Mogren-Kuzma

Learning Objectives The student will be able to describe the current and projected nursing shortage. The student will understand contributing factors impacting the nursing shortage. The student will be able to acknowledge the impact of nursing shortage on patient care. The student will recognize strategies to address the nursing shortage.

Introduction The nursing shortage affects every aspect of health care delivery in the United States. The problem of the global nursing shortage is cyclic in nature. Thus, it seems certain that shortages of nurses will continue to reoccur with a certain degree of regularity. The National Center for Health Workforce Analysis suggested that by 2020, approximately 36% of nursing positions would not be filled. The need for nurses has been described as cyclic in nature. Throughout history, countries worldwide have experienced numerous surpluses and shortages of nurses. However, the current shortage is unlike those experienced in the past and is in fact global in nature. Trends of an ageing workforce and a limited supply of available nurses filling vacancies are some of the unique aspects that bring a new dimension to an old problem. The American Nurses Association projects that the nursing shortage will grow to a staggering 1 million RNs by the year 2020 if the nursing shortage is not aggressively addressed (Dotson, Dave, & Cazier, 2012).

Shortage History The nursing shortage has commonly been referred to in terms of supply and demand. Since the World War II, the United States has gone through cyclic shortages of nurses. In the 1990’s hospitals reduced their numbers of employed RNs to contain costs. A few years later, a nursing shortage was emphasized when the hospitals experienced an increased demand for nurses. The nursing shortage has commonly been referred to in terms of supply and demand. Since the World War II, the United States has gone through cyclic shortages of nurses. In the 1990’s hospitals reduced their numbers of employed RNs to contain costs. A few years later, a nursing shortage was emphasized when the hospitals experienced an increased demand for nurses (Dotson, Dave, & Cazier, 2012).

Shortage History In the presence of good economy, many nurses moved away from traditional positions to new emerging roles in healthcare, creating vacancies in hospitals. In the recent recession, many nurses were forced to reenter the workforce to supplement or support their families economically. As the economy recovers, many RNs are likely to retire. In the presence of good economy, many nurses moved away from traditional positions to new emerging roles in healthcare, creating vacancies in hospitals. In the recent recession, many nurses were forced to reenter the workforce to supplement or support their families economically. As the economy recovers, many RNs are likely to retire (Zinn, Guglielmi, Davis, & Moses, 2012).

Where are we today? Demand by 2020 will exceed supply by 29%-36%. Increased demand due to aging Baby Boom population (people born between 1947 and 1962) and nursing workforce retiring. The nursing shortage exists in every state of the United States and by 2020 the predicted demand will exceed the supply by 29%-36%. The demand for RNs will continue to grow as the US population grows and as the average age of the nation's population increases. In particular, as the current members of the Baby Boom generation age, these Baby Boomers will create an increased demand for nursing care that will further strain the health care system (Zinn, et al., 2012).

Demand and Supply National supply and demand projections for RNs: 2000-2020 Projected supply and demand of nurses 2000-2020.

States with Shortages in 2000 Shortages by state States with Shortages in 2000 Shortages in 2000

States with projected shortages in 2020 Shortages by state States with projected shortages in 2020 Shortages in 2020

Today’s Shortage The present shortage has been described as being different in many ways from prior shortages. Several factors have been identified as contributing to the shortage: Aging workforce Educational bottlenecking Changing work climate A number of factors have been identified as a culmination to the current nursing shortage. An aging nursing workforce and an aging population requiring intense health care needs, a decrease in enrollment of nursing students, a decline in nursing salaries relative to other career groups, steep population growth in several states, and the nature of the work climate leading to burnout, job dissatisfaction and nurses leaving the profession for other careers (Zinn et al., 2012). The nursing shortage affects all aspect of health care delivery as these issues are occurring just as job opportunities within health care are expanding and a majority of nurses intend on retiring between 2011-2020. Dotson et al., (2012) introduced a new perspective to the shortage debate; they claim that it is not a shortage of the physical number of nurses, rather a shortage of nurses that are willing to work in the work environment of the present conditions. They state that there are many nurses engaged in other professions, unrelated to nursing (Dotson et al., 2012).

Aging Workforce Retiring Nurses Aging of Baby Boomers Average age of employed RNs is 45.5 years. 45% of the nursing workforce is older than 50 years of age. majority of nurses intend on retiring between 2011-2020. Aging of Baby Boomers - More health care services needed. The aging workforce of nurses is one of the most concerning factors as the shortage is expected to intensify as baby boomers age and the need for healthcare grows. According to Kovner, Brewer, Fairchild, Poornima, Hongsoo, and Djukic (2007), during the 1960s and 1970s, nursing experienced its largest influx of women into the profession. However, since a proliferation of new career opportunities for women in the 1980s and 1990s, fewer women have entered the nursing profession. Consequently, the average age of employed RNs is 45.5 years, and over 45% of the nursing workforce is older than 50 years (Kovner et al., 2007). In the same way, the aging population of baby boomers reaches their 60’s and beyond, they will require more intense healthcare services. Essentially, majority of the nursing workforce will reach retirement at a time of high demand as individuals are requiring increased nursing services.

Age Distribution of RNs: 1980, 2000 and 2020 Projected Aging Workforce Age Distribution of RNs: 1980, 2000 and 2020 Projected

Educational Bottlenecking Nursing school enrollment is not growing fast enough to meet the projected demand of nurses. Faculty shortage Low compensation Insufficient number of clinical sites Budget constraints Research suggests that one of the causes to the shortage is because nursing schools are turning away applicants due to insufficient number of faculty, clinical sites, clinical preceptors, classroom space and budget constraints (Wyte-Lake, Tran, Bowman, Needleman, & Dobalian, 2013). Wyte-Lake et al., (2013) reports of 1,181 full -time and 753 part- time vacancies of nursing faculty in the academic year of 2012-2013. Similar to the nursing shortage, the nursing faculty shortage is a multifactorial problem. Challenging satisfaction, role expectations, and workload demands of nursing faculty coupled with poor financial compensation, projected retirement and a “diminishing pipeline” of prepared students for faculty positions are some of the problematic factors contributing to the shortage (Wyte-Lake et al., 2013, p. 245).

Changing Work Climate Stressful working conditions leads to dissatisfaction, high turnover, and low retention. Short staffing High nurse-patient-ratio Mandatory overtime Low compensation Abusive environment The literature often describes the environment in which nurses’ work as stressful and abusive. Poor working conditions include insufficient staff, insufficient supplies, and insufficient care facilities coupled with low wages and disruptive behavior. The poor work environment impacts job satisfaction, nurse retention, and many times drives nurses to leave their profession. Additionally, this portrayal severs as a deterrent to new recruits (Censullo, 2008).

Root Cause Analysis The Nursing Shortage Aging workforce Declining enrollment to nursing schools Changing work environment causing low retention, high turnover, burnout, and change of profession The nursing profession is rapidly changing and is coming under increasing strain due to a variety of factors. Determining a root cause analysis heightens awareness of new factors contributing to RN shortage elements, including the ageing of the nursing workforce, declining enrolment to nursing schools, and changing work environment.

Inferences and Implications The nursing shortage adversely affects patient outcomes and satisfaction. Shortage of registered nurses, in combination with an increased workload, poses a potential threat to the quality of care. High nurse- patient ratio is associated with increased patient mortality. RN shortage negatively impacts patient care and undermining the quality of care goals set by the Institute of Medicine and the National Quality Forum. Many recent studies points to a strong connection between adequate levels of registered nurses and safe patient care. Shortage of registered nurses, in combination with an increased workload, poses a potential threat to the quality of care. A comprehensive analysis of several national surveys on the nursing workforce found that majority of nurses reported that the RN shortage is negatively impacting patient care and undermining the quality of care goals set by the Institute of Medicine and the National Quality Forum. In one study, 93% of surveyed RNs report major problems with having enough time to maintain patient safety, detect complications early, and collaborate with other team members. Results from a National Survey on Consumers' Experiences with Patient Safety and Quality Information were released and found that 40% of Americans think the quality of health care has worsened in the last five years (AACN, 2012).

Inferences and Implications The nursing shortage causing insufficient staffing is raising the stress level of nurses, impacting job satisfaction, and driving many nurses to leave the profession. The change in work environment is also causing a high turnover rate of RNs. MacKusick & Minick (2010) reports that an estimated 30-50% of newly licensed RNs elect to leave nursing completely or change positions within the three first years of clinical practice. Increased acuity and complexity of patient care, short staffing, difficult environments as well as low compensation are factors contributing to nurses’ increased dissatisfaction and consequently, low nurse retention and an increased nursing shortage.

Inferences and Implications Licensed Registered Nurses not employed in nursing

Nursing Theory Benner’s Stages of Nursing Proficiency Process of five stages of nursing practice Novice Advanced Beginner Competent Practitioner Proficient Practitioner Expert Practitioner The nursing shortage as it is exaggerated by high turnover rates by newly licensed RNs can be explained by Patricia Benner’s theory; Stages of Nursing Proficiency. In a study aimed to investigate reasons for newly licensed RNs leaving the clinical setting, unfriendly work environment, emotional distress related to patient care, and fatigue and exhaustion were listed as primary reasons (MacKusick & Minick, 2010). New nursing graduates are expected to translate knowledge, principles, and theories learned in school into their practice in a particular setting with specific patient populations. This application to practice not only encompasses new clinical skills and techniques but also includes coping with issues of relationships with patients and families, organizational structure, and group work that may be new to them. Relationships with others on the healthcare team affect the feeling of belonging in the nursing profession and in the workplace. With the transition from newcomer to insider comes the pressure to fit into the culture of the workplace. Dealing with resistant staff, feeling uncomfortable with posing new ideas, or questioning accepted practice, may put novice nurses at an increased chance of changing position leaving the profession until they become more proficient in skills and comfortable in their role as a nurse (Chitty & Black, 2011).

Competent Practitioner Proficient Practitioner Nursing Theory Benner’s Stages of Nursing Proficiency Novice No expertise Limited practical skills Relies on rules and expectations of others for direction Advanced Beginner Marginally competent skills Difficulty establishing priorities Competent Practitioner Feels competent and organized Plans and sets goals Proficient Practitioner Views patients holistically focuses on long term goals Expert Practitioner Performs fluidly Expertise comes naturally Advancing from stage to stage occurs gradually as nurses gain more experience in patient care (Chitty & Black, 2011).

Social Theory Theory of Reasoned Action (TRA) developed by Fishbein in 1967. An approach to understanding individuals’ complex decision-making processes. TRA specifically focuses on the role of personal intention in determining whether a behavior will occur. Low retention and high turnover is a causative factor to the nursing shortage. An effort to explain nurses’ intent to leave the profession and high turnover behavior can be done using the TRA. According to the theory, decision-making begins with beliefs, attitudes toward the behavior and intention, and it ends with the behavior itself (Liou, 2008).

Social Theory A person’s intention is a function of three basic determinants: - Attitude - Subjective norms - Perceived behavioral control Intention is the cognitive representation of a person's readiness to perform a given behavior, and it is considered to be the immediate precursor of a person’s actions. Intention is determined by three things: attitude toward the specific behavior, subjective norms, and perceived behavioral control (Liou, 2008).

Social Theory How it Relates to RN Turnover Intention: Leaving current position or the nursing profession Attitude: Poor job satisfaction Subjective Norms: Cultural variations, social pressure, career advancement Perceived Behavioral Control: Social support, financial ability to make a change Only specific attitudes toward the behavior in question can be expected to predict that behavior. Subjective norms refers to individual’s global perception of social pressure to act or the individual’s perception of whether their most important referents wish them to perform or not perform the behavior. Perceived behavioral control refers to people's perceptions of their ability to perform a given behavior (Liou, 2008).

Social Theory A general rule, the more favorable the attitude and the subjective norm, and the greater the perceived behavioral control the stronger should the person’s intention to perform the behavior in question.

ANA Standards Quality of Practice Collaboration Professional Practice Evaluation The American Nurse Association (ANA) has set forth standards of practice for the nursing profession that each licensed nurse has an obligation to adhere to and uphold. Standards of practice important for safety and quality improvement in regards to a nursing shortage involve quality of practice where the nurse is “using indicators to monitor quality, safety, and effectiveness of nursing practice” (ANA, 2010, p. 52). Collaborating with professional of all disciplines is imperative to provide high quality care for patients. Collaboration entails the nurse to collaborate with the patient, their family, and others in the conduct of nursing practice (ANA, 2010). Professional practice evaluation states, “The registered nurse evaluates her or his own nursing practice in relation to professional practice standards and guidelines, relevant statues, rules and regulations” (ANA, 2010, p. 59).

QSEN Competencies Patient safety Quality Improvement Teamwork and Collaboration The current nursing shortage underscores significant safety and quality problems. The QSEN competencies relevant to this seminar are patient safety, quality improvement and teamwork, and collaboration.

Quality and Safety Improvements Solutions to the nursing shortage must be addressed in ways other than short term solutions. Efforts must be aimed both at recruitment and retention. Increasing nursing school faculty. Improving work environments for nurses.

Quality and Safety Improvements Suggested Strategies Improving workplace conditions. Encourage nurses who left nursing to reenter the workforce. Enhancing education and professional development. Nurse residency programs for new graduates to help facilitate confidence, competence, and decreasing stress levels. . Structural, legal, and cultural changes would need to be implemented in order reverse and repair the nursing shortage. These changes are not expected to happen overnight, but are critical to sustain the nursing supply for the future.

Discussion Questions Discuss how the effects of the current nursing shortage impact your professional practice and your future as a nurse. Describe how quality and safety of patient care could be affected. Censullo (2008) describes several factors contributing to the nursing shortage. Pick one and explain what you think could be a potential solution to that particular issue. The work environment for nurses is often described as stressful and abusive. Name things that you can do to improve the environment for yourself and your coworkers.

References American Association of Colleges of Nursing. (2012, August). Nursing shortage fact sheet (Fact Sheet). Retrieved from American Association of Colleges of Nursing: http://www.aacn.nche.edu/media-relations/fact- sheets/nursing shortage American Nurses Association (2010). Nursing: Scope and Standards of Practice (2nd Ed.). Silver Spring, Maryland: Author Censullo, J. L. (2008). The nursing shortage: Breach of ideology as an unexplored cause. Advances in Nursing Science, 31(4), E11- E18. doi: 10.1097/01.ANS.0000341417.88715.2d Dotson, M. J., Dave, D. S., & Cazier, J. A. (2012). Addressing the nursing shortage: A critical health care issue. Health Marketing Quarterly, 29(4), 311-328. doi: 10.1080/07359683.2012.732861

References Egenes, K. J. (2012). The nursing shortage in the U.S.: A historical perspective. Journal of Illinios Nursing, 10(4), 18-22. Retrieved from http://0- web.ebscohost.com.libcat.ferris.edu/ehost/pdfviewer Kovner, C. T., Brewer, C. S., Fairchild, S., Poornima, S., Hongsoo, K., & Djukic, M. (2007). Newly licensed RNs’ characteristics, work attitudes, and intentions to work. American Journal of Nursing, 107(9), 58-70. doi: 10.1097/01.NAJ.0000287512.31006.66 Liou, S. (2008). Nurses’ intention to leave: Critically analyze the theory of reasoned action and organizational commitment model. Journal of Nursing Management, 17(1), 92-99. doi: 1 0.1111/j.1365-2834.2008.00873.x

References MacKusick, C. I., & Minick, P. (2010). Why are nurses leaving? Findings from an initial qualitative study on nursing attrition. Medsurge Nursing, 19(6), 335. Retrieved from http://0-g o.galegroup.com.libcat.ferris.edu/ Wyte-Lake, T., Tran, K., Bowman, C. C., Needleman, J., & Dobalian, A. (2013). A systematic review of strategies to address the clinical nursing faculty shortage. Journal of Nursing Education, 52(5), 245-252. doi: 10.3928/01484834-20130213-02 Zinn, J. L., Guglielmi, C. L., Davis, P. P., & Moses, C. (2012). Addressing the nursing shortage: The need for nurse residency programs. AORN, 93(6), 652–657. Retrieved from http://0- www.sciencedirect.com.libcat.ferris.edu/science/article/pii/S000 1209212009581