December 2000 579

An international registered nurse (RN) shortage,worse than any previous one, is predicted. The

reasons are complex and include both societal andprofessional factors. They are1-4:1. An aging nursing workforce. The average age of

nurses is 42 to 46 years; baby boomers (thoseborn between 1946 and 1964) will start to retire inor before the year 2011. California predicts that50% of their nurses will no longer be practicing bythe year 2012.5

2. Declining nursing school enrollment for newnurses, with older nursing students. The averageage of the new graduate nurse is 31 years old.

3. Increasing opportunities within and outside ofnursing because of a robust economy. Nursing ishard, demanding work in an environment ofmany lucrative opportunities.

4. Growing demand. The Bureau of Labor Statisticspredicts that the RN job market will grow 23% bythe year 2006.1 By the year 2020, the prediction isthat the need for RNs will rise 36%.6

5. Changing post-baby-boomer demographics. Asmaller pool of future workers is coupled with in-creased volume and acuity in health care. Thepopulation of those 82 years of age and older isgrowing at a rate that is 6 times faster than therest of the population.7 The US Census Bureau es-timates that by 2020, the number of people 85years or older will have doubled.6

6. Increasing preference of “greying” nurses to workpart time. This trend results in vacant staff RNhours, even with the same number of working

nurses. Nationwide, one study found a 20%deficit in available staff RN hours.8

7. Resulting ramifications of health care re-engi-neering. Job redesign often excessively burdenedthe RN. In fact, in 1996, American Hospital Asso-ciation (AHA) President Dick Davidson warnednational hospital executives about the “thinning”of nursing staff.9 In addition, some hospitalsbegan demanding unlimited mandatory overtimeto cover their current nursing shortage, resultingin the exit of many experienced, but overwhelmed,nurses from the profession.

The solutionTo find a solution to this problem, processes beyondstop-gap measures need to be considered. Suggestedapproaches include traditional, short-term, and long-term proposals.

Traditional approachesOne traditional answer focuses on attractive financialoptions, such as referral fees or higher compensation,to recruit a nurse.8,10 However, a sign-on bonus losesits luster without gaining loyalty once the nurse is onstaff. Hiring just anyone, even when a manager knowsthe applicant is the wrong person for the job, creates alose/lose situation that only compounds the problem.

Enticing current employees to work more hours isanother approach.8,10 Premium pay is offered to existing

Polly Gerber Zimmermann, Illinois ENA, is Instructor, Departmentof Nursing, Harry S Truman College, and Associate Nurse, Ameri-can Airlines, Chicago O’Hare International Airport, Chicago, Ill.For reprints, write: Polly Gerber Zimmermann, RN, MS, MBA, CEN,4200 North Francisco, Chicago, IL 60618; E-mail: pzimmermann@ccc.edu.J Emerg Nurs 2000;26:579-82.Copyright © 2000 by the Emergency Nurses Association.0099-1767/2000 $12.00 + 0 18/9/111528doi:10.1067/men.2000.111528

Clinical NotebookThe nursing shortage: What can we do?Author: Polly Gerber Zimmermann, RN, MS, MBA, CEN, Chicago, Ill

The Bureau of LaborStatistics predicts that theRN job market will grow23% by the year 2006. Bythe year 2020, the predictionis that the need for RNs willrise 36%.

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staff. They voluntarily increase their hours for a peri-od of time, often over a known seasonal shortage suchas summer vacations or Christmas holidays.

However, the Lawrenz Consulting annual staffsurveys indicate a high incidence of nurse burnoutwhen a facility’s overtime hours reach more than 13%to 15%.11 Circadian experts recommend that personslimit their overtime hours to 300 to 350 per year.12

Short-term approachesRestructure orientation and mentoring, especially for thenew graduate. Many hospitals are beginning to realizethat effective preceptorships are vital, especially fornew nurse graduates. Although the overall national RNturnover rates are around 14%, one survey found that20% of new RN graduates leave during their first year ofhospital employment. Anecdotally, it is as high as 50%.8

Instead of scaling back on training, as the AHAindicates many hospitals have done,6 Johns Hopkins’Senior Director Amy Deutschendorf, MS, RN, AOCN,suggests expansion of training. She plans to provideextra assistance throughout the first year of practice.Her orientation program includes mandatory compe-tencies, gradual hierarchical introduction of responsi-bilities, and adjusting the patient loads for the orien-tee/preceptor pair.8

Invest/reward staff longevity.8 A 1999 survey by LawrenzConsulting11 found that in the hospitals that respond-ed, the average budget for education was 3.5%, com-pared with most successful industries, which invest5%.

Deutschendorf also advocates use of additionaltraining resources, pointing out that re-engineeringresulted in the loss of the clinical specialist in manyhospitals. That role was pivotal in assisting nurseswith on-the-job learning in today’s rapidly changinghealth care environment. One compensating solutionis that many hospitals offer didactic classes, pairedwith a personalized “internship,” to develop their spe-cialty nurses.

Adjust the hospital work environment to make it more ap-pealing. Changes with managed care and federal Med-icaid and Medicare reimbursements have affectedhospitals’ revenue. The AHA estimates that 1500 hos-pitals are operating in the red.6 However, nursing ser-vices were cut even in financially thriving hospitals topreserve historic profit levels.9 Whereas hospitals reg-ularly blame an RN shortage for staffing deficiencies,in reality, the problem is more often a shortage of nurs-es willing to work with the current conditions intoday’s hospitals.9 Nurses want a decent and safe at-mosphere and staffing levels in which to practice.

JOURNAL OF EMERGENCY NURSING/Zimmermann

The legitimacy of their concerns is coming to theforefront. Of the top 11 JCAHO sentinel events, 5 havea proven relationship to staffing and 3 have an anec-dotal relationship to staffing.8 Investigative reporterBerens blames working conditions that place exces-sive pressure on RNs, rather than incompetent indi-viduals, for nursing errors. He found that since 1995, atleast 1720 patients have been accidentally killed and9584 patients have been accidentally injured by RNs.9

As a result of working conditions, many nurses havechosen to leave bedside care. It is predicted they willreturn when the environment is fixed.

Use more accurate measures of accounting for the nurseworkload for appropriate staffing. Historically, the mid-night census and ED total patient census determinedstaffing numbers. Yet patients are not equal. In addi-tion to acuity concerns, increased nursing time is in-volved in the activity of patient admissions, dis-charges, transfers, and holds of today’s shortenedlength of stay.

For emergency departments, one promising im-provement is a more precise triage scale with inter-rater reliability and test/retest accuracy. The refinedEmergency Severity Index (ESI), developed byRichard Wuerz, MD, and colleagues at the Brighamand Women’s Hospital in Boston, has a statisticallysignificant correlation to the patient’s vital status. Al-ready it has validated the high acuity of theBrigham’s ED population and is being used in con-sideration of adjusting staffing levels.13-15

Reexamine the concept of partnering with higher level as-sistants. Unlicensed assistive personnel (UAP) remaina concern. Under the care of nurse aides, 564 US hos-pital patients have been injured since 1995.9

California enacted mandatory patient staffingratio legislation, sponsored by the California NursesAssociation, in 1999. The law included strict UAP jobdescription guidelines that eliminate procedures nor-mally done by nurses. These procedures includevenipuncture, tube feedings, invasive procedures (in-cluding insertion of nasogastric tubes, catheters, ortracheal suctioning), and/or postdischarge care.16

Consultant Marie Manthey, RN, MSN, states thatthe most effective use of an auxiliary partner is whenthat role can do 75% of what the RN can do. Then agroup of responsibilities can be delegated, rather thanan isolated task. She advocates the increased use oflicensed practical nurses, partnered consistently withthe same RN.8 However, many ED managers reportunderutilization when persons in higher trained as-sistive roles, such as a respiratory therapist, replaceRNs.17

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Consider mandated staffing ratios. A controversial sug-gested solution is that of the California legislation,which requires a minimum, specific, licensed nurse-to-patient ratio for all acute care hospital units.16

More than 20 other states are considering similarlegislature.

Some oppose this approach because they fear thatminimum staffing levels will become the ceiling. Thissituation could possibly lead to required staffing num-bers that are unsafe at times. An involved trauma casemay require a number of RNs. Other factors, such asskill mix and staff competency, are also considerations.

Recruit from other countries. Nearly 1 in 10 Canadiannursing graduates from 1995-1997 migrated to theUnited States.18 Recruiting hospitals report thatthese nurses are well-trained, have excellent skills,and easily adjust to the differences in our health caresystem.8

Long-term approachesReconsider how nurses are being used. Consultant HollyA. DeGroot advocates examining to what extent nurs-es are spending their time nursing. For example, oneICU had a staffing ratio of 1:2, but the RNs spent lesstime on direct patient care than did RNs on other unitsbecause they lacked supportive systems, such as unitclerks and equipment delivery. Documentation is an-other time-consuming task. Nurses in one emergencydepartment spent the equivalent of 6.8 full-time em-ployees per day (eg, 54 hours) on charting.8,19,20

From a different angle, consultant Cavouras sug-gests including unit clerks and assistive personnel inthe hospital’s float pool. Otherwise, the temptation to“just send a nurse” occurs when the staffing needcould often be met adequately by someone with lesstraining.8

Accommodate the older worker.4,7 Keeping older nursesworking in the hospital, even part time, provides staffand experience. Human Resource Director John Vicikadvises changing job descriptions, benefits, sched-ules, training, and recruitment to accomplish thisgoal. He suggests the following:1. Create a descending clinical ladder, allowing

nurses to fill positions with less responsibility forless compensation, similar to what is done inJapan.

2. Offer benefits that older workers typically value,such as vision care or shorter shifts, rather thanchild care.

3. Accommodate normal aging changes, such ashaving training materials in larger print on non-glossy paper.

4. Recruit in senior citizen centers and churches in-stead of the classified ads, which most olderworkers do not read.Cavouras reports that a lift team has been a

tremendous source of satisfaction at one rural hospi-tal. A team of young employees and a mechanical lift,instead of “greying” nurses, provide this physical ser-vice for heavier patients.8

Reexamine registered nurses’ wages. Nursing wageshave basically remained flat in the environment of agrowing economy.9 Nursing experience and educationare not appropriately rewarded. Just as teachers haveclamored for fair compensation for their work, nursesneed to insist their vital work be adequately rewardedfinancially.

Begin active recruitment among untapped adult candi-dates. The profession often overlooks traditionalbut promising sources of future nurses. Many cur-rent, non-nursing hospital employees chose towork in a health care environment because theyenjoy helping others. Having a local college’s nurs-ing program recruit right at the hospital is an ef-fective technique.

Many recent immigrants see nursing as offeringa higher entry-level income than most other associatedegree–level opportunities. English as a SecondLanguage classes or ethnic cultural centers areprospective places to begin to foster an awareness ofthe opportunities available in nursing.

Improve nursing’s image. When nurses are not able togive adequate care, it is important to convey that.One floor’s staff even wrote in large letters across thepatient identification board, “We are not able to givegood care today because we are short staffed.”

Even in trying times, most nurses can recallmeaningful moments of touching another person’slife. Few professions offer such immeasurable

One ICU had a staffing ratioof 1:2, but the RNs spentless time on direct patientcare than did RNs on otherunits because they lackedsupportive systems, such asunit clerks and equipmentdelivery.

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rewards. Nurses need to emphasize these rewardswhen talking with the public. Also, continued vigi-lance for accurate media portrayals, such as a recentmobilization against one company’s ad that portrayeda nurse as scatter-brained, is important.

Instill the nursing vision in young children. Positivecontacts with children can be initiated with activ-ities ranging from teddy bear clinics to school vis-its. Many of today’s nurses recall the impact of animpressionable story or encounter on their ownlives.

A call to nursing’s rootsA range of opinions about what can be done to ad-dress this pending nursing shortage exists. The an-swers are still evolving. However, no expert suggestsreplacing the trained, educated, socialized RN with apiecemeal distribution of tasks to lesser qualifiedUAPs. Repeated studies show that such actions havea negative impact on quality patient care. Decreasesin RN staffing coincide with a rise in hospital errors,infection rates, and readmissions. The higher ratio ofRNs to non-RNs, specifically the RN hours of care perpatient per day, has been proved to improve patientcare outcomes.21-24

Editor Leah Curtin sounds the summarizingtheme by calling nurses back to their roots. Nursing isa profession which, by definition, focuses on helpingand giving. The emphasis of nursing is not business,which is a focus on production and profits. In the end,stressing nursing ideals will help restore the magnet-ic pull to its life-changing work.25

References

1. Curtin L. A crisis in the making: key facts. CurtinCalls1999;1:15.2. Silvestri GT. Occupational employment projections to2006. 1997, November. Monthly labor review. Washington,DC: Bureau of Labor Statistics.3. Sloane M. Survey says…more nurses needed. Nurs Spectr1999;12:16.4. Zimmermann PG. Healthcare institutions get out of thebox and on the edge with the nursing shortage. Nurs Spectr2000;13:28-9.5. Jacobs C. Kaiser’s workforce initiative. CurtinCalls1999;1:7-10.6. Berens M. Training often takes a back seat. Chicago Tri-bune 2000 Sept 11;Sect. 1:1, 6, 7.7. Vicik J. Recruitment/retention. In: Zimmermann PG.Manager’s forum. J Emerg Nurs 2000;26:367.8. Zimmermann PG. Manager’s forum. J Emerg Nurs. In press.

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9. Berens MJ. Nursing mistakes kill, injure thousands.Chicago Tribune 2000 Sept 10;Sect. 1:1, 20, 21.10. Labarre L, Jones S. Recruitment/retention. In: Zimmer-mann PG. Manager’s forum. J Emerg Nurs 2000;26:363-7.11. Lawrenz Consulting Group. 2000 Staffing survey results.Perspect Staffing Scheduling 2000;19:1-6. [The Perspec-tives on Staffing and Scheduling is a bimonthly publicationof Lawrenz Consulting, 9012 N Cobre Drive, Phoenix, AZ85038; phone (602)788-0027.]12. Coburn E, Sinois W. A lifestyle how-to for night-shiftnurses. Nurs Manage 2000;31;28-9.13. Wuerz RC, Milne LW, Eitel DR, Travers D, Gilboy N. Re-liability and validity of a new five-level triage instrument.Acad Emerg Med 2000;7:236-42.14. Wuerz R, Travers D, Gilboy N, Yazhari R, Eitel D. Imple-mentation of five-level triage at two university hospitals.Poster at Society for Academic Emergency Medicine An-nual Meeting, San Francisco, CA, May 2000.15. Travers DA, Waller AW, Bowling JM, Flowers DF. Com-parison of 3-level and 5-level triage acuity systems [ab-stract]. Acad Emerg Med 2000;7:233.16. Farella C. California staffing law gains national atten-tion. Nurs Spectr 2000;13:11.17. Griswold A. In: Zimmermann PG. Manager’s forum. JEmerg Nurs 1997;23:641-2.18. Pond C. Northern exposure. NurseWeek 2000;13:1, 31.19. DeGroot HA. Patient classification systems and staff-ing, part 1: problems and promise. J Nurs Adm 1994;24:-43-51.20. DeGroot HA. Patient classification system and staffing,part 2: practice and process. J Nurs Adm 1994;24:17-23.21. Blegen MA, Goode CJ, Reed L. Nursing staffing and pa-tient outcomes. Nurs Res 1999;47:43-50.22. Kovner C, Gergen PJ. Nursing staffing levels and ad-verse events following surgery in US hospitals. Image JNurs Sch 1998;30:315-21.23. Bond CA, Raehl CL, Pitterie ME, Franke T. Healthcareprofessional staffing, hospital characteristics, and hospitalmortality rates. Pharmacotherapy 1999;19:130-8.24. Moore K, Lynn MR, McMillen BJ, Evans S. Implementa-tion of the ANA report card. J Nurs Adm 1999;29:48-54.25. Curtin L. Mandated ratios in a downsized market[keynote address]. Presented at A Staffing Crisis: Nurse/Pa-tient Ratios [sponsored by CurtinCalls and Cross CountryUniversity]; 2000 July 21-3; Washington, DC.

Send descriptions of procedures in emergency careand/or quick-reference charts suitable for placingin reference file or notebook to Gail PisarcikLenehan, RN, EdD, c/o Managing Editor; PO Box489, Downers Grove, IL 60515; phone (630) 663-1263; E-mail: khalm@ena.org.