by Courtney Haun, MPH, AL-HAC, Program Assistant
According to the 2016 America’s Health Rankings Annual Report, the United States (U.S.) ranks 26th of 35 Organization for Economic Co-operation and Development countries for life expectancy (“Comparison With Other Nations | 2016 Annual Report | AHR,” 2016). The rank is a result of a comprehensive set of data to allow a holistic view of the health of each individual state and the entire nation at large. Based on the nation’s health ranking alone, it is evident that there is a health crisis in the U.S. that needs to be improved upon.
One reason for the poor health outcomes may be attributed to the nursing shortage issue (Keenan & Kennedy, 2003). Many states are projected to operate within a persistent and sustaining nursing shortage (ANA, 2014; Kaiser Family Foundation, 2016). Additionally, many majority rural states rank with the lowest amount of nurses (HRSA, 2015). By 2020, there will be 1.6 million nursing job openings, 700,000 of which will be newly created jobs (Carnevale, Smith, & Gulish, 2015).
To fill the shortage gap, nursing schools and qualified nursing faculty within those schools are needed. According to the American Association of Colleges of Nursing, “Faculty shortages at nursing schools across the country are limiting student capacity at a time when the need for nurses continues to grow. Budget constraints, an aging faculty, and increasing job competition from clinical sites have contributed to this emerging crisis” (Rosseter, n.d.).
In the nation, there are currently 2,043 nursing schools (“Schools | Discover Nursing,” 2017). Out of those schools, 1,554 have data stored with the National League of Nursing’s Biennial Survey of Schools of Nursing. Based on the survey, 2,350 qualified applications to nursing programs were turned away for two primary reasons: lack of clinical placement settings and lack of faculty (National League of Nursing, 2015). Therefore, this information suggests that many individuals want to earn a career in nursing; however, there is an issue with the amount of nursing faculty to meet the demand.
Based on the above information, the future of the nation’s nursing market is dim if appropriate solutions are not discovered specifically for this state. The issue is complex and has many factors associated with it. Understanding these multiple variables is critical when formulating solutions to the problem. Furthermore, “outside” factors such as legislation and technology advancements must be considered. There is a deep relationship between all of these aspects which contributes to the complexity of a perfect solution (“American Association of Colleges of Nursing | Strategies to Reverse the New Nursing Shortage,” n.d.). It is important to know and understand that the healthcare system in the U.S. is far different than it used to be and it is continually changing. To find healthcare solutions, the nursing market issue is one facet that will need to be correct.
Although there is no simple solution to the nursing shortage problem, many efforts are being made to rectify the issue. Despite the conglomeration of factors facing an effective solution, some possibilities can contribute to repairing the nursing market. Solutions range from recruitment activities, reducing turnover rates, and even implementing laws and regulations. The following paragraphs dive into some of the major solutions that are being tested and tried across the U.S.
Nursing Student Recruitment Initiatives
Many solutions are being aimed at the recruitment of more nursing students and faculty throughout the nation. One solution is allowing the aging practicing nurses to educate new nurses. By combining the practice of nursing and the education behind that practice, both generational groups could come up with solutions of their own for the shortage crisis. However, for this to even work there must be some recruitment of students. Efforts are already taking place to recruit high school students and educate them about the nursing field. To aid in this effort, some hospital systems in the U.S. are creating “support programs” to add more faculty and student slots to colleges. Texas A&M offers another approach. At this school, according to the American Hospital Association, there has been an estimate of $425,000 in scholarships given from a local hospital for local students to complete a four-year bachelor’s program in nursing (Nevidjon & Erickson, 2001). Collaborative efforts, such as the examples above, are a glimpse at the various solutions to the nursing shortage problem.
Nursing Faculty Recruitment Initiatives
As mentioned, nursing school faculty may be in a shortage as well as the active working nurses. Despite this issue, efforts are being made to recruit more students into nursing. The ANA is developing campaigns (along with other organizations) to recruit new nurses into the field and encourage those who are already in the field to remain in the profession. To retain nurses, it takes a combination of efforts from orientations to preceptor programs. These recruitment efforts, of course, require a great deal of funding. New approaches are also being made to consider a nurse throughout an entire career, not just getting them into an organization (Peterson, 2001). Recruitment costs go far beyond getting a supply of nurses into the profession. “A study commissioned by the American Hospital Association, the Association of American Medical Colleges, the Federation of American Hospitals and the National Association of Public Hospitals and Health Systems found that the share of all hospitals paying sign-on bonuses as part of recruitment efforts more than doubled, from 19 percent in 1999 to 41 percent just two years later” (“The Cost of Failure,” n.d.). Also, recruitment time takes approximately 54 to 109 days (“2016 National Healthcare Retention; RN Staffing Report,” 2016). However, this is not the same in all regions of the country (“2016 National Healthcare Retention; RN Staffing Report,” 2016).
Diminishing the high nursing turnover rate is another facet to a solution. Although retaining a nurse may go beyond how the organization values its staff, this is foundational to understanding the nursing turnover issue. This paradigm shift could be including leadership in efforts to learn new skills on how to value employees. Attracting and retaining staff is vital to health care facilities success in the ever-present competitive market (Nevidjon & Erickson, 2001). Although this will be different based on personal nurse’s ideas and attitudes in the workplace, some common themes have been identified when it comes to why there is such high nursing turnover. These include “autonomy, salaries, schedules, credibility gap, and professional respect” (Nevidjon & Erickson, 2001). This goes hand-in-hand with overall job dissatisfaction. Leaders in healthcare must learn what exactly is driving job dissatisfaction for their nurses which, in turn, is leading to turnover. After finding these issues that are particular to a specific organization, creating flexible and supportive policies and benefits should be made accordingly (Nevidjon & Erickson, 2001).
Regulation and policy implementation is also of high prominence for nursing shortage solutions. There are already a number of regulatory and policy issues that are playing a vital role in the nursing shortage dilemma. It is thought that this political environment may be making the shortage even worse. Nurses are leaving the profession, and there are barriers to recruitment of new nurses for a variety of reasons. This is caused by a culmination of “state and federal law, regulation by accreditation/certification organizations, licensure and nursing practice acts, and requirements from reimbursement organizations, private organizations and the government” (Nevidjon & Erickson, 2001).
Federal regulations have been long-standing because of the understanding of how crucial nurses are to the healthcare system. Table 1 is a brief timeline of major legislation that has come to fruition in light of nursing shortage (Glazer & Alexandre, 2008). This is a rendition of a summary report made by Glazer and Alexandre, whom all of the credit it owed (Glazer & Alexandre, 2008).
In recent years, there have been a number of statewide legislative initiatives. According to the American Association of Colleges of Nursing, Illinois, Kansas, Maryland, and Utah are working to address the shortage of Registered Nurses and nurse educators by creating Nurse Support Programs, Assistance Funds, Scholarship Funds, and Education Expansion Programs (AACN, 2006). Colorado, Georgia, Nebraska, Minnesota, and Texas have focused efforts on alleviating the shortage of nurse educators by expanding student capacity in their educational institutions. Some ways they are doing this is through a Nursing Teacher Loan Forgiveness Program, Nursing Faculty Fellowship Program, and a Nursing Education Loan Program. Massachusetts, Missouri, and Pennsylvania, are working inside and outside of the legislative arena to launch programs involving strong collaborations between education, practice, and community stakeholders (AACN, 2006).
Other pieces of legislation are attempting to correct the nursing shortage issue through regulations focused on the patient-to-nurse ratio. The legislation is different among all states, however. In 1999, California adopted a law mandating patient-to-nurse ratio for its hospitals, which went into effect in 2004. The California legislation intended to address the increasing nursing shortage and the belief that high nursing turnover was due to work overload which also caused job dissatisfaction. In 2004, California’s governor proclaimed that hospitals must have a least one licensed nurse for every six medical and surgical patients (Aiken, 2010).
According to Aiken, most California nurses believed the ratio legislation achieved its goal by reducing workloads, improving recruitment, retention of nurses, and having an increased impact on quality of care. The research also reports the higher the percentage of nurses in hospitals whose patient assignment is aligned with the California mandated-ratios, the lower the nurse burnout, job dissatisfaction, the less likely nurses are to miss changes in their patients’ conditions (Aiken, 2010). Improved nursing ratio standards have been further edified and supported through other various research as well (Bowblis, 2011; Cho & Yun, 2009; Dellefield, Castle, & McGilton, 2015; Nuikka et al., 2001).
Possible Challenges to Solutions
Despite the policies, regulations, and rules that have been made at multiple levels, the U.S. still suffers from a shortage within the nursing profession (Staiger, Auerbach, & Buerhaus, 2012). It is evident that there are still gaps in the solutions (HRSA, 2002). The depth of the issue goes far beyond the costs associated with it and, because of this, it is necessary to improve nursing staffing. The political environment surrounding nursing is vast, but it has not reaped the appropriate outcomes needed. If there is still a shortage, there is still a problem. It is clear that policies, up to this point, have not made a significant difference in reducing the costs of the nursing shortage. In fact, there are millions of dollars poured into the issue with not much return on the investments. Also, as mentioned, there are already several ongoing initiatives taking place. Some actions have been through political incentives (e.g. laws and regulation), and others are more on an organizational/private level. For solutions to be created and implemented, it requires a mix of research that gives a reason why to do something and then policy to mandate the appropriate solutions found to work. Future research objectives could evaluate the extent to which these policies are making a difference and which ones are of waste. Currently, there are an array of policies being implemented at the state and national level. These are convoluted, and it is unclear which are working and which are not. Although some of these are great ideas to boost the nursing workforce, there is still shortage present in a significant amount of states (Carnevale et al., 2015).
|1943||The federal government created the U.S. Cadet Corps to provide support for nursing education.|
|1963||Surgeon General’s Consultant Group on Nursing identified an impending shortage of nurses and prompted Congress to pass the Nurse Training Act which added Title VIII to the Public Service Act. The Nurse Training Act provided funding in the form of construction grants for nursing schools, student loan programs, education grants, and traineeships for advanced practice nurses.|
|1998||Health Professions Education Partnerships Act of 1998 created the National Advisory Council on Nurse Education and Practice (NACNEP) to advise the federal government on policy within Title VIII.|
|2002||The NACNEP cited the need to ensure the availability of an adequate number of qualified nursing faculties to teach prospective students.|
|2002||The Nurse Reinvestment Act of 2002 amended Title VIII to incorporate key recommendations of NACNEP including career ladders to recruit and retain nurses; nurse education, practice, and retention grants; internships and residencies; comprehensive geriatric education; nurse faculty loans; and the Nurse Scholarship Program.|
|2005||Nursing was added as an area of need under the Graduate Assistance in Areas of National Need (GAANN) program via the Higher Education Act allowing schools of nursing to fund research-focused doctoral students.|
|2006||U. S. Department of Education released a report noting $2.4 million was awarded to 14 programs to support 57 nurses in doctoral programs.|
|2007||The Bureau of Health Professions in the Health Research and Services Administration (HRSA) awarded $37 million through a total of 134 education, practice, and retention grants to basic nursing education programs.|
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