Is the Shortage of Hospital Registered Nurses Getting Better or Worse? Findings from Two Recent National Surveys of RNs

Peter I. Buerhaus; Karen Donelan; Beth T. Ulrich; Linda Norman; Robert Dittus

Disclosures

Nurs Econ. 2005;23(2):61-71,96. 

In This Article

Discussion

The results of two recent national surveys of RNs that were conducted at a time when the nursing shortage in the United States was in full force (2002) and 2 years later (2004) were compared. Because many of the same questions were used in both surveys, it was possible to detect changes in RNs' perceptions on a variety of issues related to the nursing shortage over this period. The analysis was restricted to RNs working in direct care positions in hospitals. Overall, the findings provide a mixed assessment: on the one hand, there is evidence that the shortage has eased since 2002 and that there have been notable improvements in the lives of nurses; on the other hand, the shortage has had a negative impact on hospitals and nurses, and long-standing problems associated with the workplace environment remain.

While the majority of RNs perceive the supply of RNs is less than demand in the communities in which they practice, the size of the shortage has eased as RNs perceived the magnitude of the imbalance between supply and demand has narrowed since 2002. This finding is not surprising given the huge increase in hospital employment of RNs in 2002 and 2003. What is surprising, however, is that nearly nine in ten RNs in 2004 continued to perceive a nursing shortage in the organizations where they worked. A 2004 national survey of physicians also found that most (81%) physicians perceived a national shortage of RNs in the hospitals where they admitted patients (Buerhaus, Donelan, Norman, & Dittus, 2005).

That RNs perceived the nursing shortage is continuing could be accounted for by two explanations. First, despite the preceding 2-year surge in employment growth, many RNs in 2004 may believe that staffing did not increase enough to enable them to provide the amount and quality of nursing care they believe is needed by patients. Thus, even though employment of RNs rose considerably in the 2 years between the two national surveys, RNs may have perceived the increase as inadequate and, therefore, the shortage had not been resolved. Second, the demand for RNs may have been rising during the past few years, as was projected to occur by the federal government (U.S. Department of Health and Human Services, 2002). Thus, the recent expansion in the size of the RN workforce may not have been large enough to close the gap caused by the concurrent rise in demand. In this case, RNs would still be reporting shortages even though more RNs were working. Both explanations may have been operating simultaneously.

Although the recent increase in hospital RN earnings and employment were apparently unable to reduce RNs' perception of a nursing shortage in 2004, these developments may help explain several positive findings revealed in the surveys. From 2002 to 2004, RNs observed a reduction in total overtime and mandatory overtime, an increase in the amount of voluntary overtime, and fewer RNs perceived the main reasons for the shortage involved inadequate salary and benefits, more career options, undesirable hours, and a negative work environment.

While the nursing shortage may be getting better in some ways, nevertheless, it has affected hospitals negatively as the majority of RNs observed reductions in the number of hospital beds, increased patient wait time for surgery or tests, delayed discharges, and increased complaints about nurses. The shortage is perceived as a major problem for nurses as well, particularly in detecting patient complications early, maintaining patient safety and quality of care, time to spend with patients, and in nurses' own quality of life. (A more comprehensive discussion of RNs' perceptions of the shortage on the quality of care will be provided in part four of this six-part series.) To a lesser extent, RNs also perceive that physician workloads have increased as a consequence of the nursing shortage. Unless the shortage is resolved, these negative effects will likely continue.

To reduce the negative effects of the shortage, hospitals have implemented various recruitment and retention strategies. Although most strategies had not been widely observed by RNs, nearly all of the strategies assessed in the 2004 survey were perceived to be effective by at least half of the RNs who had observed them. Of the recruitment strategies, offering flexible work schedules, providing tuition benefits, giving signing bonuses, and increasing salaries were perceived as effective strategies by at least two-thirds of RNs. On the other hand, two out of three RNs did not perceive efforts to recruit foreign graduates as effective, a perception that might reflect RNs' opposition to this strategy rather than their perception of its effectiveness. Turning to retention strategies, those perceived as effective by the majority of RNs include mentoring programs for recent graduates, paying for continuing education, and reimbursing fees for attending conferences. Two strategies, providing financial incentives for quality improvement and offering online schedule bidding, were the least observed retention strategies, perhaps because they are relatively new methods and thus used by fewer hospitals. That nearly eight in ten RNs who had observed online schedule bidding perceived this as ineffective in retaining RNs suggests that hospitals may wish to exercise caution in implementing this strategy.

The strategies to solve the nursing shortage drawing the most agreement in both surveys included improving the work environment, increasing salaries and benefits, and raising the status of nurses in the hospital. Because hospitals are unlikely to be able to raise RN earnings year after year, it may be more productive for hospitals to focus on addressing nonwage strategies. Undoubtedly, many hospitals have attempted to create a better workplace climate by implementing the recommendations of recent reports from the American Hospital Association (2002), Joint Commission on Accreditation of Healthcare Organizations (2002), and the Institute of Medicine (2004). However, because the organizational culture and working environment differ from one hospital to another, chief nurse and hospital executives should assess and continually monitor the work environment in their organizations to determine the specific areas needing improvement, and how these improvements can be achieved quickly and efficiently from the perspective of nurses. Similarly, hospitals should try to discover what nurses mean by "raising the status of nurses" and then proceed to make appropriate changes to address this deficit. More on the survey findings of RNs' perceptions of the work environment can be found elsewhere (Ulrich, Donelan, Buerhaus, Norman, & Dittus, 2005).

The 2004 national survey of RNs makes clear the urgency with which hospitals and nurses need to work together to improve the state of hospital nursing as only one-fifth of RNs perceive that the current shortage will lead to improved working conditions or increased respect for nurses. Moreover, the vast majority perceive the shortage will increase stress, lower quality of care, lead to nurses leaving nursing for other jobs, and other staff will be needed to perform some nursing patient care activities. Less than half of RNs believe that wages will rise in the future or that respect for nurses will grow. Holding such negative perceptions of the future may indicate that many RNs have given up hope and believe their work life is unlikely to improve. Moreover, holding such pessimistic expectations about the future means that RNs may have less attachment and loyalty to the organization, and be less inclined to offer a positive recommendation about nursing to those who might be considering a nursing career. Thus, beyond focusing on improving the workplace climate, hospitals also might offer programs or resources that help RNs discover ways to achieve a better balance in their lives and cope more effectively with what is a difficult and challenging job (Borgatti, 2004).

Although hospitals, nurses, physicians, nursing educators, and policymakers can take some measure of satisfaction that the current nursing shortage has eased and there has been some improvements in the workplace environment over the past few years, nevertheless, this study indicates that much work remains to be done if we are to build a solid and well-prepared nursing workforce for the future. Fortunately, the large increase in the number of RNs employed by hospitals since 2001 and the finding that more RNs in 2004 than in 2002 indicated they had no plans for leaving their nursing position within the next 3 years, may provide the time needed to improve the work environment and retain the workforce. It also may prevent RNs' negative expectations of where the shortage will lead to in the future from materializing. From the perspective of RNs, the most important changes that would cause a reconsideration of plans to leave their positions include better staffing and higher salaries and benefits, followed by more respect from management, administration, and front-line management, and more flexible schedules — all of which are under management's ability to address.

In part two of this six-part series, the focus will be directed away from the nursing shortage and toward RNs' perceptions of the nursing profession itself, whether they are satisfied with being a nurse, and would recommend nursing to others. RNs' satisfaction with their job in general and on specific elements of their work experience, the quality of their relationships, and other dimensions of being a nurse will also be examined.

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