Politics, Economics, and Nursing Shortages: A Critical Look at United States Government Policies

Rob Elgie, BSN, RN, BC


Nurs Econ. 2007;25(5):285-292. 

In This Article


Much could also be accomplished with national and state policies that enhance the status of advanced practice nurses (APN) such as nurse practitioners (NP) and clinical nurse specialists (CNS). These are nurses who have reached the pinnacle of clinical nursing practice, and serve as beacons to attract young students to nursing. They provide role models to nurses already in the profession with ideals for which to strive. Vouchers for advanced nurse education in the NRA put downward pressure on compensation for APNs by providing an artificial supply required by contract vouchers to work after graduation in facilities where there is little incentive to provide fair compensation.

National and state policies should eliminate disparities in reimbursement rates for APNs and encourage APNs to serve on the boards of managed care insurance providers. The Medicare Payment Advisory Commission (2002) re ports that NPs, CNSs, and physician assistants are paid only 85% of what physicians are reimbursed for identical services. Policies such as these threaten NPs with the implication that they belong to a second rate profession.

Nurse practitioners are generally excluded from the boards of managed care organizations, and as a result NPs report intense frustration (Hayes, 2003). Nurse practitioners are an excellent source of clinical management expertise and should be permitted to put management courses included in their training to good use on managed care boards. The inclusion of NPs and other APNs on managed care boards would foster positive attitudes toward managed care operations to attract and retain NPs as role models at the pinnacle of clinical nursing practice.

Finally, language in the NRA alludes vaguely to the idea of enhancing nurse retention through the award of grants that enhance career ladder programs and patient care delivery systems (Senate of the United States, 2002). Concept u ally, this section of the NRA draws on key principles proven to enhance nurse recruitment and retention known as Magnet Status Accreditation that has a positive influence on nursing workforce supply equilibrium. As an alternative to current NRA policy, however, a great deal more can be done to offer incentives for hospitals to achieve Magnet status conditions.

The concept of Magnet status began in 1983 when the ANA conducted a survey of 163 hospitals across the nation. The study identified 41 hospitals with key success factors that served to attract and retain nurses. Among the key success factors were staff autonomy, management involvement, administrative support, and sufficient staffing ratios (Fetters-Anderson, 2003). These key factors have evolved into a formal award pro cess by the American Nurses Cre dentialing Center (ANCC) known as the Magnet Nursing Services Recog nition for Excellence in Nursing Services; 242 health care organizations in 44 states achieved Magnet status recognition by June 2007 (ANCC, 2007).

The American Federation of State, County, and Municipal Em ployees (AFSCME, 2005) links patient outcomes with conditions that lead to improved nurse recruitment and retention found in Magnet status accredited hospitals. AFSCME endorses certain characteristics of Magnet-accredited hospitals that improve nurse recruitment and retention to in clude competitive compensation, optimal staffing ratios, scheduling improvements, enhanced support for education, power over policies, and professional practices such as primary nursing that enhance nurses' satisfaction with their work. In a survey of nurses who were considering leaving the profession, 71% said the most enjoyable part of their jobs was helping patients and families, implying that nurses who leave nursing do not lack commitment but rather are not permitted to care for their patients the way they want (AFSCME, 2005).

The Joint Commission for Accreditation of Hospital Organi zations (JCAHO) president states: "Magnet hospitals fare substantially better than other hospitals in recruiting and retaining nurses" (AFSCME, 2005). A white paper on the nursing shortage by JCAHO (2005) notes that there are no incentives built into the reimbursement system to encourage optimal nursing or even safe patient care. Therefore, one JCAHO policy recommendation is to link reimbursement to the quality of nursing services and patient outcomes. This, in effect, would move nurses "...from the cost side of the balance sheet to the asset side" (p. 35). Such a shift would provide economic incentive for hospitals to cultivate Magnet status characteristics in their nursing services.

As a documented example of putting such Magnet hospital characteristics into action, working mothers and fathers at the Cleve land Clinic Foundation hospitals can participate in the Parent Shift schedule that lets nurses work 2 to 6-hour shifts, starting and stopping whenever they like. The Cleveland Clinic Foundation provides a model for hospital employee relations with other innovative nurse-retention policies that have earned its debut on Working Mother Magazine's "100 Best Companies" list (Evans, 2006).


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