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Issues Surrounding the Nursing Shortage
In the early 2000s, national strategies to improve the nursing workforce profile were largely focused on increasing the number of nurses at the bedside through the use of sign-on bonuses and travel nurses. While these strategies tended to provide local short-term solutions, they did little to address long-term issues affecting the nursing shortage. With nursing education programs challenged to increase student enrollment, many colleges were confronted with a limited financial infrastructure, a shortage of qualified faculty, and difficulty establishing the clinical sites needed to support additional students. Thus, they found themselves turning qualified applicants away (Clark & Allison-Jones, 2011).
According to the American Association of Colleges of Nursing (AACN, 2010) there are three routes to becoming a registered nurse (RN), a 3-year diploma program typically administered in hospitals, a 3-year associate degree usually offered at community colleges, and the 4-year baccalaureate degree offered at senior colleges and universities.
This paper will examine the past and current issues revolving around the nursing shortage, compare the competences of associate degree level of nursing (ADN) with graduates of Bachelor of Science Nursing (BSN) programs, and explore the concept of differentiating competencies.
A quick review of the literature reveals that the current nursing shortage is nothing new. Roberta Spohn wrote, "Although there are recurring reports of manpower shortages in many other professional fields, nursing seems to enjoy the dubious distinction of continually suffering from this condition" (Spohn, 1954, p. 865, in Fox & Abrahamson, 2009). Though this quote sounds like it fits into the contemporary nursing dialog, it was written over 50 years ago. Despite short-lived periods of adequacy in nurse availability, the nursing shortage has endured due to a variety of reasons.
Research reveals that there was concern about a nursing shortage between 1930 and 1950. The number of hospitals in the United States changed very little during that period. However, what did increase was the number of beds within hospitals; 52% more beds were reported in 1952 than in 1932. The daily patient census of hospitals increased at the same percentage. At first glance, it would appear that the increase in hospital capacity alone could account for this period's shortage of nurse caregivers; however the problem was far more complex. A closer examination of the problem showed that the increase in hospital capacity, and therefore patients, could not single-handedly have caused this shortage because average length of stay had decreased significantly during this same time frame. As a result, many more patients were being seen annually, but were staying for shorter periods of time, which, in turn, did not increase the average number of patients requiring care on any given day. Investigators cannot simply consider admission statistics as an accurate measure of nursing demand; the number of nurses necessary to adequately care for a population is a far more complex question (Fox & Abrahamson, 2009).
Early research revealed that a number of societal factors influence the number of nurses entering or exiting the U.S. labor market, including accreditation policy, educational opportunities, U.S. entrance into foreign conflict, and cultural image of the profession (Fox & Abrahamson, 2009).
A Shortage of nurses was instrumental in the development of the associate degree (ADN) level of nursing. According to Lauren Huber (2006) after the Second World War many nurses who were in the military or civilian practice were leaving the profession, and fewer students were choosing nursing as a career. To exacerbate the problem those that did enter the profession were leaving after only a few years.
Meanwhile advances in medical science, improved medical facilities and an increase in the number of insured worked to create an increased demand for nurses. Simultaneously the growth in junior colleges, an increase in the availability federal funding, and public concern led to the inclusion of nursing into the junior college curricula. Initially the ADN was foreseen as a temporary solution to address this shortage and was not intended to replace the professional level of nursing education, however, ADN programs, first introduced in 1958, became instantly popular and expanded throughout the 1960s. Raines and Taglaireni (2008) report that currently there are about 940 ADN programs nationwide with approximately 600 of these offered in the community college system. The typical ADN program is a two-year commitment and prepares graduates with the clinical competence and technical proficiency needed to practice safely in multiple settings and to fully assume the RN role.
In the 1980s attention focused on organizational factors when it was found that the prospective payment system introduced to hospitals in the late 1970s had an effect on the availability of nurses. Research indicated that the legislation had a dampening effect on nurse salaries at a time when other professional salaries were rising, influencing nurses to leave the profession.
During the 1990s, hospitals experienced two major RN shortages. The first shortage began in 1990 and was marked by an 11% vacancy rate of unfilled, full-time RN positions. However, by 1992, the shortage appeared to have subsided and the status of the nursing supply was optimistic. Only 5 years later, in 1997, hospitals began to feel the pressure of a shortage again and by 2001, the national average hospital RN vacancy rate was at 13%. Unlike the shortages of the past, this shortage has not receded and remains a topic of current policy discussion. Although some interested parties have tried to isolate one factor as the reason for the shortage such as low pay, the reality may be that a web of dysfunction exists that is far more complicated than any one single factor.
Shortages in other skilled professions tend to be short lived, with supply catching up with demand as soon as potential employees receive information of incentives offered to attain market equilibrium. That this is not the case for nursing encourages further examination of the forces which permit the nursing shortage to endure. The biggest factor in any labor shortage, lack of qualified potential applicants, surprisingly, is not a problem in nursing. In fact, nursing schools are turning away qualified applicants because of lack of available faculty and resources. There are enough licensed RNs and qualified nursing school applicants in the United States that the United States has the potential to independently staff its healthcare facilities without drawing from foreign nurse labor markets. Hundreds of thousands of RNs have removed themselves from the active nursing workforce, while an inadequate number of younger nurses are selecting nursing as a profession. In order to alleviate staffing shortages, the societal and occupational factors which discourage people from choosing to practice nursing must be examined.
Members of the baby-boomer generation were born roughly between 1946 and 1964. The high birth rate during this time resulted in a large population increase. However, after 1964, for the next 11 years, the birth rate dropped dramatically. In the 1990 census, there were 77 million baby boomers compared with 44 million in the following generation, sometimes referred to as Generation X This population imbalance creates a challenge for the nursing profession; as baby boomers age their demands upon the healthcare system increase. The increase in patient census, along with the multisystem medical needs and function-based care required by an aging population, puts pressure on the professional nurse workforce. Conversely, nurses who themselves are members of the baby boomer generation are aging. That means that nearly half of RN's are projected to be over age fifty by 2010 and the average age of nurses rises to above forty-five. Retirees and aging nurses leaving the workforce are not being replaced in adequate numbers with newly trained, younger nurses. Thus, the current mechanisms for training nurses must be examined.
Hospital-based diploma programs once served as the United States' primary mechanism for training nurses. Hospitals came to depend on student nurses who were required to spend long hours providing care on the wards. As nursing education moved from primarily a hospital-based system to colleges and universities, a larger paid nursing staff became necessary to provide the same level of patient care. This put pressure on fledgling university-based programs, which struggled, and continue to struggle, with attaining adequate numbers of graduate degreed nurse faculty. In the 2005 -- 2006 academic year, at least 41,683 qualified applicants were turned away from baccalaureate, masters, and doctoral nursing programs. This is a major increase from the approximately 32,797 qualified applicants turned away in 2004. Of those schools that turned applicants away, more than 74% cited lack of faculty as the primary reason.
Female college graduates, historically the population most likely to select nursing as a profession, have seen their educational options and professional opportunities expand in recent decades. A recent survey of adult Americans found that although 83% of respondents would encourage a loved one to pursue a career as an RN, only 21% would consider this career for themselves, and only one in ten male respondents would consider a career in nursing. Increased diversity of career options, coupled with a tightened admission structure in nursing…[continue]
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