Guest Editorial

Nursing shortage: A crisis for the next decade

Dorcas C Fitzgerald
RN Track Coordinator, Department of Nursing, Youngstown State University, United States of America

PP: 109

Article Text

Another nursing shortage exists. However, this one is quite different as no recovery is projected! Instead, healthcare literature and government statistical data predict that this shortage will last into the 2020s due to its multi-faceted and multi-disciplinary causes. Another dissimilarity, this is a global shortage, and international recruitment, which has been a quick-fix intervention in previous shortages, becomes an ethical issue. Australia, Canada, Central America and the Caribbean, Lebanon, Norway, Philippines, Southern Africa, United Kingdom, and the United States report shortages of nurses in healthcare literature.

'Aging', too, is a major distinction in this shortage with several of the countries listed above identifying an increasing elderly citizenry as influencing the nursing shortage. In the United States, nurses average 44.5 years of age; nursing faculty assistant and associate professors are 49 and 52, respectively; and an aging society with the largest cohort group, the 'Baby Boomers', turning 65 in less than a decade. These statistics, alone, suggest during the next decade the shortage of nurses will be termed a healthcare crisis. Hence, long-term recovery interventions are needed. Although many other antecedents of this shortage are the same as previous ones, another factor compounding the problem of quality healthcare services is the numerous vacancies in other health professions. These healthcare workforce shortages denote that the healthcare industry is a fundamental culprit.

Rapid and ever-changing healthcare delivery, reimbursement issues, and management controls have created a complex, stressful environment from which health professionals are exiting. Findings from studies in several countries have identified stress and dissatisfaction related to these 'workplace issues' as problems in the retention and recruitment of nurses. The complexities of the fast-paced, specialized and technological-intensive patient-care units and frequently understaffed environment often create an atmosphere where the nursing care given is contrary to the wholistic manner nurses deem appropriate. These feelings of guilt, in addition to the increased overtime hours, lack of sufficient support staff, feelings of powerlessness, physical exhaustion, and inadequate wages are causing nurses to exit the profession. In a recent survey of RNs in the U.S., men were found to be leaving nursing at a faster rate than females. They listed the search for better wages, more-rewarding work, more-flexible hours, and more autonomy as reasons for their career changes.

Nursing education programs and student recruitment and attrition rates have also been affected by these problems, which now can be described as chronic due to its longevity and unremitting progression. With such a grim outlook, the problem-solving questions of 'who, what, and when' are paramount. This is not a 'band-aid' situation but one in which continuous therapy and rehabilitation will be needed for the next few years.

All nurses as professionals, citizens, and healthcare consumers have a stake in the retention and recruitment of nurses, as well as in the revision of healthcare services. Staff nurses, who are most in demand due to critical staff shortages, have recruitment responsibilities, and these cannot be disregarded or left to nursing administrators and nursing schools.

Ways staff nurses can recruit
Please welcome and mentor nursing students when they are on your unit. Many students have expressed to this instructor how un-welcomed they have felt when on the clinical unit, as well as received the comment: 'Get out of nursing now!' Nursing students should be respected for their assistance in sharing the patient care workload during the learning experience and for their eagerness to become our future colleagues. Wear your name-tag proudly and within sight for each patient, and introduce yourself to each patient and family stating your name and your position as a registered nurse. Every patient deserves to know that a competent professional is caring for him/her. These communication techniques augment the image of nursing and influence recruitment. In addition, work with your nursing organization(s) and healthcare employers in resolving workplace problems and in recruiting and retention activities.

Recruiting abroad
Few articles have been written in nursing literature concerning international recruiting. However, a national news service conducted an investigative television show about some American healthcare institutions recruiting abroad. This author talked with a recruiter for a large medical center who has recruited in the Philippines. Since depleting nurses from another country during this global shortage may endanger the healthcare of the citizens of that country, such tactics seem to conflict with the Code of Ethics for Nurses. However, recognizing the rights of an individual to migrate in search of a better standard of life is an inherent ethical consideration of the profession, too. The recruiter spoke as if she were a missionary there to rescue nurses, who in turn will bring family members to the United States for a better economic future.

The relocation of these nurses is expected to take 18–24 months to complete and is expensive when calculating the four recruiters' traveling expenses, plus the fees for the agency there, travel for the nurses and family members, licensure preparation, and housing for several months upon arrival. If healthcare agencies can budget these activities, I question why monies weren't used earlier to increase nursing salaries and to improve the healthcare environment as incentives to retain nurses. Wages have been cited by nurses in several counties as impacting their decision to quit. Nurses' salaries have remained relatively flat for the past decade. Another economic problem for nurses is retirement benefits. Starting salaries are adequate; however, salaries peak within 4–5 years with nurses not being adequately compensated for their experience and seniority and, often, are not compensated for advanced education. Maybe if the monies had been used for these benefits, nurses would not have left the profession, thereby lessening the impact of this shortage.

Older nurse retention and recruitment
Loss of the experienced, older nurse can only be described as 'brain drain.' Although, knowledge of life-span growth and developmental needs is well-known, nursing care delivery has not been revised to accommodate the needs of middle-aged nurses. Belgium has instituted shorter work-weeks for their older nurses. Nurses, 45–55, work 36 hours per week and get paid for 38 hours, while nurses 55 and older work 32 and get paid for 38.

Other incentives to meet the needs of nurses in their 40s and 50s include:

1. 'Buffet benefits' in which the part-time employed nurse can select certain benefits needed to compliment additional household income and benefits received from a spouse or social services;
2. Shorter work days of 4–6 hours instead of the 8–12 hours, which can be physically exhausting;
3. Job sharing in which two nurses agree to share a 40 hour work week with the nurses deciding themselves how to split the hours, as well as how the benefits will be divided. [This makes staff scheduling easier, as the two are considered one position.];
4. Intergenerational daycare services for older nurses caring for aged parents. [Many hospitals have daycare centers within the institution for younger nurses' children, but the same service is not available for nurses' older parents. Intergenerational daycares could provide many grandparent–grandchild type relationships in which both the young child and older person would thrive.];
5. Free 'refresher courses' to entice nurses who left the profession to raise their children and now want to return, but are fearful of the much changed environment. [In the States, refresher courses are expensive, offered infrequently, and are often only regionally located, thereby, involving distant travel.]; and
6. Eliminate the 'one-size-fits-all' method of hiring. Most hospitals hire nurses as a general staff position on a medical–surgical unit, and then, after six or more months the nurse may request a transfer to a preferred unit, one less strenuous or one in which she has had the most expertise. [Last month, I was appalled by this situation. While conversing with a salesperson at a dress shop, I learned that she was an RN and questioned why she was working there and not as nurse. She reported relocating to the area several months earlier because of her husband's job transfer, and when she sought employment as a nurse with area hospitals, she was told that all new employees must begin as a staff nurse on a medical–surgical floor with options later to transfer to areas of interest or expertise. She stated: 'I have had more than 10 years experience as a nurse manager on a surgi-care unit; that's where my expertise is; and since I am in my mid-fifties, that type of unit is better for me physically.' I have heard similar complaints regarding this hiring practice.]

Growing your own
Healthcare agencies, as well as academic institutions, should over tuition reimbursements with a return commitment policy for unlicensed employees to become a nurse or nurses to seek advanced degrees. Although many agencies do offer partial tuition reimbursements, often the policy only applies to full-time employees with no adjustment of the employee's work schedule. The healthcare agencies should partner with local and/or regional colleges or universities for courses that could be offered at the healthcare facility either with a visiting professor, by interactive distance learning (IDL) modality, or Web-CT (internet-based courses). Agencies should recruit at schools of nursing with offers to pay for the last year or two of nursing education in exchange for an employment commitment post graduation.

In the U.S., academic salaries average $10–15,000 lower for a nursing faculty member than her clinical counterpart employed by a healthcare agency, which is a main deterrent in recruiting faculty. Thus, to curb the nursing faculty shortage, educational reimbursement benefits should be offered by academic institutions to attain and retain faculty. Reduced tuition packages for the faculty member's dependents to attend the employing institution are faculty incentives, as well as means to increase enrollment.

Several universities now offer summer programming for earning a doctorate in nursing. These programs are usually 8–10 week terms for 3–4 summers to complete the course work, plus the doctoral research and writing the dissertation. Relocation for a few weeks in the summer is usually manageable when relocating for two years or more is not. Subsequently, the masters prepared faculty member can fulfill her teaching responsibilities during the academic calendar and, then, become a student during the summer. In addition, some graduate and post-graduated courses are offered by Web-CT and IDL. Regardless of the modality, graduate education is expensive, but a well-prepared, committed nursing faculty member is worth the school's investment and may be enticed to come and stay if benefits offset the low salaries. Another method of increasing nursing faculty is to share clinical appointments with institutions. That is, a nurse may be leased to the academic institution for 1–2 days per week for clinical instruction of students. This can be win–win situation as the students receive clinical instruction from an expert in a particular specialty, and the two institutions share salary costs.

Recruitment of youth
Schools usually begin career education for children in the upper elementary grades. Therefore, nurses should offer to speak at career days, and healthcare institutions should send several nurses of various roles to 'tell their stories' of nursing and the courses needed in middle and high schools to prepare for nursing school. Healthcare agencies should have career days in which students are invited to learn 'what nurses and other health professionals do.' Make nursing career information available and nurses visible in your community. There is a drastic need for such activities to recruit nurses for the next decade to ensure the provision of quality healthcare services.

In summary, all nurses have responsibilities in the recruitment and retention of nurses, now and in the future, as well as a personal stake in healthcare services available. The activities suggested are not inclusive, but with the addition of these to the managerial changes suggested by Mr. Rylatt in the following article (Contemporary Nurse 13/2–3 (October 2002) pp 113-116), the effects of the shortage can be lessened, as well as increase the number of nurses for the future.

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