Nursing Education

The ability of the educational system to produce new graduates is affected by limited enrollment, a shift from associate degree to baccalaureate-prepared RNs, and a shortage of nursing school faculty, compounded by an insufficient number of clinical sites, classroom space, and clinical preceptors, as well as budget constraints (AACN, 2011–2012). Adding complexity, the average age of nurse faculty (60% age 50 + years; ANA, 2011) suggests a probable large surge of retirements in the near future. AACN’s report, 2010-2011 Salaries of Instructional and Administrative Nursing Faculty in Baccalaureate and Graduate Programs in Nursing, shows the following average ages of doctoral-prepared and master’s-prepared nurse faculty:

The overall numbers of nursing school enrollments is not growing fast enough to meet projected demand (Figure 20-4) for RN and APRN services into the next two decades. Even though the AACN reported a significantly higher percentage of increase (5.1%) in enrollments for entry-level baccalaureate nursing programs in 2011, the increase is not sufficient considering the implementation of the Affordable Care Act of 2010 and the impending increase of more than 32 million Americans accessing heath care services.

Clearly there is strong interest among new nursing students and across the RN workforce in advancing education. The question now becomes what is the ability of higher learning institutions to handle the high number of applicants? In the 2010-2011 academic year, the data indicated that only 39.5% of applications were accepted for entry, whereas 75,587 qualified applicants were turned away, primarily because of shortage of faculty and resource constraints. The average eligibility rate for applications submitted into entry-level baccalaureate programs was approximately 50% overall, creating a shortfall on eligible admissions of 10.5%. The top reasons given by nursing schools for not accepting all qualified applicants into entry-level baccalaureate programs include insufficient clinical teaching sites (65.2%), a lack of faculty (62.5%), limited classroom space (46.1%), insufficient preceptors (29.4%), and budget cuts (24.8%). (The graphed data on turn-aways can be found at http://aacn.nche.edu/media-relations/TurnedAway.pdf.)

The AACN survey also noted an increase in total enrollments into nursing programs, with an increase of 10% from 2010, across all baccalaureate, masters, and doctoral programs in 733 nursing schools (87.5%) in the United States. AACN reports that 80,767 students graduated from baccalaureate programs last year: “Given the call by the IOM for nurses to increase their education, AACN was pleased to see growth in degree-completion programs for RNs looking to earn their bachelor’s or master’s degree” (AACN, 2012a). For the ninth straight year, enrollment in RN-to-baccalaureate programs increased by 15.8% within a total of 814 advancement degree programs available nationwide. There are also 62 new advancement degree programs in development, marking a 7% increase in available programs.

Demographic Factors

The Bureau of Health Professions (BHPr, 2004) projected that the number of licensed RNs would remain relatively constant (2.7 million) between 2000 and 2020. The number of licensed RNs was projected to increase slightly through 2012, but “today the youngest cohorts of nurses in the workforce are projected to be the largest in history by the time they reach middle-age and will provide 30 percent more FTE RNs than the baby-boomer cohorts who are now nearing retirement” (Auerbach et al., 2011).

Aging of the RN Workforce

Understanding the demographic nature of the RN workforce requires an examination of the factors affecting the number of practitioners who may continue to work, that is, the aging of and the changing composition of the RN workforce.

The current nursing shortage may last longer because of the large number of RNs approaching retirement age and the growth and aging of the U.S. population. For example, the report by the Bureau of Health Professions (BHPr) (2006) titled, The Registered Nurse Population: Findings from the March 2004 National Sample Survey of Registered Nurses, showed that the average age of registered nurses was 46.8 years in 2004 compared with 45.2 years in 2000. According to the BHPr’s (2010) report, The Registered Nurse Population: Initial Findings from the 2008 National Sample Survey of Registered Nurses, the percentage of nurses under age 40 years grew to 29.5% of RNs, increasing their numbers by nearly 18% from the same age group in 2004. This is a very positive finding, although as it was noted by Buerhaus and colleagues (2009a), the same survey sample revealed that most surveyed RNs were white females working in hospitals located in urban and suburban areas where the average nursing age only decreased by 2 years in 2008 compared to 2006. Only 19% of RNs were under age 35 years, and 4 in 10 RNs continued to fall between the ages of 35 to 49 years and 50 years and over (Figure 20-5).

The aging of the RN workforce is affected by the following two factors: the higher average age of recent graduates, and the aging of the existing pool of licensed nurses.

• The “graying” factor makes the nursing shortage an even greater issue, as the RN loss is projected to be 128% higher in 2020 than in 2002. The graying of the existing licensed pool is evident in the following data. According to the 2008 National Sample Survey of Registered Nurses released in September 2010 by the federal BHPr, the average age of the RN population in 2008 was 46 years of age, up from 45.2 years in 2000.

• With the average age of RNs projected to be at 44.5 years in 2012, nurses in their 50s are expected to become the largest segment of the nursing workforce, accounting for almost one quarter of the RN population (Buerhaus et al., 2009c).

• Within the next 8 years, the Bureau of Labor Statistics (BLS) projects the need for 1.2 million additional nurses to fill new positions and replace those retiring from the profession.

Historically, when the unemployment rate was high, the RN workforce tended to be larger than predicted, and when unemployment was low, the RN supply decreased more than expected. An increase of 1 percentage point in the unemployment rate was associated with 1.2% increase in the size of the RN workforce (Staiger et al., 2012).

Although these figures are daunting, Auerbach and colleagues (2007) revised their forecast, noting a smaller shortage than originally projected based on trend analysis through 2005. The results of this analysis indicated that there was a larger-than-expected increase in overall interest in nursing as a second career choice, especially among people in their late 20s and early 30s. Based on the influx of nurses, their projection was that the shortage would be approximately 800,000 by the year 2020.

Clearly, recruitment and retention will be major factors in the future. Multiple approaches will be needed, coming from both political arenas and the marketplace if the shortage is to be averted or minimized in the future. Actions noted by Auerbach and colleagues (2007) for addressing the shortage were directed toward workforce planning by policy makers. They recommended that initiatives include strategies for engaging high school and college graduates to select nursing as a career, finding ways to increase nursing education program capacities, providing incentives for hospitals to continue efforts to retain older RNs, and clarifying how the use of foreign nurses will be addressed. They further noted that, in order to increase educational program capacity, faculty would have to be recruited and developed and paid a salary that is equivalent to their hospital RN counterparts.

Work Environment Factors

RN employment overall has risen from 2 million in 2001 to 2.35 million in 2007 and 2.6 million in 2008, with 63% of this increase occurring in hospitals. There were an estimated 3,063,163 licensed registered nurses living in the United States in March of 2008; this is an estimated increase of 5.3% since 2004. However, nearly all of this employment increase was supplied by older RNs and non-U.S. born nurses, the two most rapidly increasing segments of the nursing workforce today (Buerhaus, 2008).

In general terms, a nursing shortage has been shown to have adverse effects, including decreased access to care, decreased job satisfaction, and increased turnover. For example, an inadequate number of nurses to staff the operating room results in decreased OR capacity, which in turn increases wait time for surgical procedures. The concern about the effect of RN shortages on the quality of patient care is growing. The meta-analysis conducted by Kane and colleagues (2007) found that the shortage of RNs and the increased workload can negatively impact the quality of patient care. Duffield and colleagues (2007) found that stabilizing the work environment, whether by low nurse turnover, stable nurse leadership, or adequate competent staff, enhances patient outcomes.

Nurse vacancy and turnover rates are predictors of nursing shortages as well. The average nursing vacancy rate reported in 2008 was 8.1% (American Health Care Association, 2008) which represents a nearly 50% decrease from 16.1% in 2005. The turnover rate is slowly decreasing: 15.5% in 2003, and 13.9% in 2005 (AACN, 2008). However, the turnover rate for first-year nurses remains high; one survey reported 27.1% in 2007 (PricewaterhouseCoopers, 2007); another revealed 13% turnover and also found 37% of first-year nurses reporting that they felt ready to change jobs (Kovner et al., 2007).

Several work environment factors have been cited as reasons for increased turnover (Buerhaus et al., 2000; Tri-Council for Nursing, 2004), including workload, autonomy, relations with managers, and compensation. Such factors influence job stress, in turn leading to job satisfaction or dissatisfaction (Hayhurst et al., 2005) and ultimately turnover and intent to stay.

International Recruitment

According to McHugh and colleagues (2008), the U.S. recruits more internationally educated nurses (IEN) than any other country. This is evident in that the number of IENs working in the United States has tripled since the 1990s. In March of 2008, an estimated 170,235 RNs living in the United States received their initial nursing education in another country or U.S. Territory, claiming 5.6% of the total nursing population. Approximately half of the IENs were originally from the Philippines (48.7%), 11.5% from Canada, and 9.3% were from India (BHPr, 2010). In 2008 alone, a record number of 48,000 RN FTEs were filled by foreign-born nurses (Buerhaus et al., 2009a). According to McHugh and colleagues (2008), major barriers to recruitment of IENs have been related to both limited visas and ethical concerns related to depletion of nursing resources in other countries.

International recruitment has been of major concern to the International Council of Nurses (ICN) for more than a decade now. In 1999, the ICN released a position statement, Nurse Retention, Transfer and Migration, now updated as Nurse Retention and Migration (ICN, 2007a). In this document, the ICN linked the nursing shortage (inadequate supply of nurses) to lack of quality in health care. The statement addressed the individual nurse’s rights, as well as positive and negative issues related to migration. It also delineated roles that national nurses associations should take to raise nurse awareness of potential constraints and ensure that countries seeking to recruit nurses had policies and practices relative to fair and humane treatment of nurses. The ICN supports the migration of nurses as a short-term strategy for addressing the nursing shortage, viewing nurse migration as a way of increasing the nurse’s career opportunities and personal self-interests. Nurse migration is further viewed by the ICN as a way of increasing multicultural practice and learning opportunities within the nursing profession. This is especially true as nurses have identified two major reasons for leaving their home country—economic security and professional opportunity—although personal safety/security in the workplace and/or country has also been noted. However, concerns related to recruitment practices led the ICN in 2001 to issue a position statement on ethical nurse recruitment, now updated (ICN, 2007b).

In 2004, the ICN and its sister organization, the Florence Nightingale International Foundation, investigated global nursing shortage issues related to international recruitment. This global analysis aimed to identify the policy and practice issues and solutions to be considered by governments, international agencies, employers, and professional associations when addressing the supply and use of nurses. To date, this initiative has produced an overview paper and white papers addressing such issues as migration, recruitment and retention, policy and planning, the work environment, and problems specific to Latin America and sub-Saharan Africa. Those papers are available on ICN’s website (www.icn.ch).

Principles are relevant because they address changes that need to take place to ensure that nurses are treated fairly and equitably in the international marketplace. Unethical recruitment of nurses in the past has led to nurses being exploited and misled into accepting job responsibilities and work conditions incompatible with their qualifications, skills, and experiences. The ICN condemns the recruitment of nurses into countries where authorities support human rights violations. Sparacio (2005) addressed the complexity of international recruitment and the ethical impact of “brain drain” on the country from which nurses are being recruited. The California Nurses Association (CNA) and National Nurses Organizing Committee put forward a resolution, which was adopted by the CNA’s 2005 House of Delegates, outlining a code of practice for international nurse recruitment (Dumpel, 2005). This code was directed at the concerns and unlawfulness of international recruitment relative to the health care impact. The code specifically targeted human rights issues relative to accessibility and quality of care within the home country.

Although international recruitment of nurses has greatly increased in the United States in recent years, few studies have been conducted to examine the adaptation, socialization, and true “lived experience” of the IEN or foreign-born nurse working in the United States. (Jose, 2011). Even though the core values of professional nursing are universally the same, the delivery of quality nursing care is dependent upon contextual factors such as shared common language and understanding among co-workers, patients, and families (Blythe & Baumann, 2009). Recent literature suggests that overall socialization into current American culture can add additional psychological stressors and possible retention issues in the long run for international recruits. Successful adjustment of IENs in the United States is important to ensure quality patient care and financial stability for recruiting health care agencies. Jose (2011) examined the socialization of foreign-born nurses working in the United States for less than 5 years and found six common themes among them: (1) dreams of a better life, (2) a difficult journey, (3) a shocking reality, (4) rising above the challenges, (5) feeling and doing better, and (6) readiness to help others. Considering that the “American way” is most often viewed through the media in other countries, it is often misperceived as a journey to immediate affluence without the struggles. For nurses coming into this country without any prior cultural or workplace socialization, culture shock is detrimental to them and to the recruiting organization. In light of this situation, more health care organizations are using intermediary recruitment agencies to provide preliminary workforce orientation and life skills planning. Kawi and Xu (2009) similarly found that the positive work ethic of IENs and their persistence and willingness to learn and adapt will ultimately prevail in their adjustment to their new U.S. workplace and add value to the nursing workforce.

Changing Demographic Nature of the Population

Population growth and aging baby boomers are the major factors changing the demographic nature of the population, which in turn are affecting the demand for RNs. According to the Bureau of Health Professions (2004), the U.S. population will grow 18% between 2000 and 2020, which equates to an additional 50 million people requiring health care. Increased life expectancy resulting from advances in science and medicine accounts for most of this population growth, as well as the increase in the proportion of the population older than 65 years. A rapid increase in the elderly population began around 2010, when those at the top end of the baby boom generation reached age 65 years (Figure 20-6). The subgroup of people 65 years and older will grow 54% between 2000 and 2020, which equates to an additional 19 million people in this age group. This is equivalent to a tsunami wave that cannot be stopped yet has huge implications for health care delivery financing.

Individuals older than 65 years, particularly those ages 85 years and older, have the greatest per capita demand for health care and thus the greatest need for the services of RNs. These individuals tend to have (1) a higher incidence of chronic conditions such as arthritis (50%), hypertension (36%), and heart disease (32%); and (2) a higher occurrence of multiple conditions requiring more regular care. Thus with living longer and current rates of obesity comes the increased prevalence of chronic medical conditions. As a result, this population uses a larger portion of the available health care services and resources. They visit physicians twice as often as those younger than 65 years, account for 38% of hospital discharges (they represent 13% of the population), and have annual per capita health care expenditures of $5400 compared with $1500 for those younger than 65 years.

Health Delivery System

Health delivery systems form the structure around how care is delivered, where it is delivered, and how it is paid for. For example, Medicare and Medicaid reimbursement, The Patient Protection and Affordable Care Act, along with regional and local customs and cultures influence the demand for nursing services. It is commonly known that socioeconomic determinants such as culture, income, educational level, and age affect an individual’s health practices, which in turn affect the person’s health status and subsequent use of and access to health care services. Increased acuity of patients puts more demand on critical care services such as emergency and intensive care areas, thereby increasing the need for nurses. A combination of decreased supply and increasing demand creates a nursing shortage potential situation, which varies by geographic region. Urban and suburban hospitals reported higher vacancy rates than did rural hospitals, and individual and multihospital systems reported higher average RN vacancy rates than did integrated delivery systems.