Taking a Strategic Look at the Nursing ShortagePublished: September 24, 2003 in Knowledge@Emory
There are currently more than 100,000 unfilled nursing jobs across the United States and according to the U.S. Department of Health and Human Services, by the year 2020, the shortage of nurses is expected to top 800,000.
In addition, recent projections indicate that the U.S. population will grow 18% between 2000 and 2020, with those over 65 years old projected to increase 54%. This translates into 19 million people who will enter the over 65 age group by 2020, according to the Bureau of Labor Statistics’ Current Population Study. As the healthcare needs for this population increase, there will be fewer people entering the nursing profession to take care of them.
Such statistics don’t bode well for a healthcare system already in crisis. Nursing was once one of the most prestigious and accommodating professions for women. But as opportunities opened up in other arenas, the lure of the nursing profession waned. Add to this the move to managed care and emphasis on cost containment, and the groundwork for the current shortfall is set.
Alleviating the problems behind the nursing crunch will take more than a bandaid, say experts at Emory University and its Goizueta Business School. From stressful work conditions to stagnant pay, the challenges facing nursing are varied and complex.
“Because of the stress and the overwork, fewer people opt to go into the profession,” says Earl Hill, a senior lecturer in organization and management at Emory University’s Goizueta Business School. “Those factors don’t lead to a very good work/life balance.”
Indeed, a recent American Nurses Association survey found the 55% of nurses would not recommend a nursing career to their children or friends. Not surprisingly, “enrollment in nursing schools has declined dramatically over the past several years, so there’s little pipeline,” adds John Hammond, assistant dean of the evening MBA program at Goizueta and a senior lecturer of organization and management.
Additionally, many nurses are baby boomers themselves. According to a recent article in Journal of the American Medical Association, the average age of today’s nurse is nearly 45 years old and is projected to be 50 years old by 2010.
“It’s a recipe for disaster,” warns Hammond.
Building quality leaders
Forestalling such a calamity will take more than just renewed recruiting efforts. The issues impacting the business of nursing are varied and require different strategies to solve them. One key area for improvement is to enhance the nursing work environment by providing better leadership in healthcare facilities. Currently, “many of the middle managers and front line managers are nurses, and they weren’t trained in management, they were trained to be professional nurses and to provide healthcare,” observes Peter Topping, executive director of executive education and a senior lecturer in organization and management at Goizueta.
As many discover, the skill set needed for one discipline doesn’t always translate into another. As a consequence, “when you have a bad manager it creates bad morale in the whole organization,” Topping explains. “And when you’re already under great duress and then you have to deal with a bad manager the situation only gets worse.” The solution, Topping says, is to develop effective leaders who are equipped to tackle the tough task of reshaping the healthcare environment. “If we can grow the capacity of the leadership inside the organization, then we can begin to look at how to restructure and reorganize and transform this organization—given the resources we have—into one that is more effective in meeting its mission.”
To this end, many nursing schools, including The Nell Hodgson Woodruff School of Nursing and the Woodruff Health Sciences Organization at Emory University, have launched programs that integrate business and management principles into the core health curriculum. For instance, Emory launched the Woodruff Leadership Academy in 2002. This program is open to professionals who have been identified as future leaders and work in areas that comprise the health sciences at Emory, including the school of nursing. “Through this program, we help equip these identified ‘leaders’ to make the transition from highly skilled professional to manager/leader of others,” says Topping.
Marla Salmon, the dean of Emory’s Woodruff school of nursing, points out that so-called Magnet hospitals (hospitals certified by the American Nurses Credentialing Center as having achieved excellence in providing nursing services) are able to retain nurses and provide better quality healthcare because of good leadership.
“In these hospitals, they have developed a work environment that explicitly values nurses. This is reflected by senior leadership, which is comprised of nurses who are trained to be in leadership positions. These hospitals not only give their nurses the responsibility for managing the patient care enterprise, if you will, but also the authority and the respect and collaborative teamwork from physician colleagues to do it,” notes Salmon.
“There’s a fundamental respect [in these hospitals] for what nurses bring and the view that nurses are one of the most important investments you can make in having a high quality, effective and efficient enterprise,” Salmon contends. “Leadership has a whole lot to do with this.”
Using technology to reduce non-nursing tasks
Improving the work environment also entails streamlining processes.
An American Hospital Association study published in 2001 notes that for every hour of patient care given, 30 to 60 minutes were spent on the resultant paperwork.
Siemens Medical Solutions, one of the largest suppliers of medical technology and information technology to the healthcare industry world wide, is trying to reduce the amount of time nurses spend doing non-nursing tasks.
“We are working closely with facilities to re-engineer their processes,” says Rosemary Kennedy, a registered nurse and market manager of Siemens Nursing Informatics, Clinical Systems Group. “We’re integrating technology into best practice processes in order to improve efficiency and quality.”
Nurses armed with electronic devices have access to lab results, progress notes, assessments and other information at the point of care. Now, nurses always have the most current information at their fingertips, facilitating decision making and teamwork among caregivers. Technological advances have also streamlined data entry and documentation, and minimized redundancy--thereby reducing the amount of paperwork.
Technology can bring dramatic improvements in workflow by automating a broad range of healthcare processes, which helps nurses spend more time with the patient. “This technology allows you to pro-actively manage the care of the patient, thus improving quality and operational efficiency,” says Kennedy.
Increasing the teaching pool
Another component of the nursing shortage is the lack of educators to teach students. According to a 2002 Joint Commission on Accreditation of Healthcare Organizations report, nursing schools turned away 5,000 qualified baccalaureate program applicants in 2001. Why? Not enough educators. In Georgia alone, 25% of nursing school faculty is slated to step down between 2002 and 2006.
To combat this trend, Emory’s Woodruff school launched a post-masters certificate institute in 2003 that prepares individuals with strong clinical connections to be educators. The school also opened a second-degree program that enables people with degrees who are interested in returning to nursing with a clear course of study.
These programs are possible, notes Salmon, because of the resources of the Emory University system and its atmosphere of collaboration. “We have a special role in creating innovative strategies at the leading edge, for others to hopefully adopt and to generalize.”
Redefining what it means to be a nurse
Salmon would also like to see an increase in federal, corporate and private funding to provide more nursing scholarships, to create and develop faculty positions, to improve educational facilities, and to add residency and mentoring programs in hospitals.
One corporation doing its part is Johnson & Johnson. In 2001, the company launched a two-year, $20 million “Discover Nursing” campaign, and is using its marketing and advertising muscle to reposition nursing as a highly versatile profession. Additionally, the company is providing scholarships for students and for those aspiring to become nursing school faculty.
“The medical profession has some work to do in terms of reformulating what it means to be a nurse,” notes Goizueta’s Hammond. “Certainly it’s worth the effort. Nurses are the largest occupational group in the healthcare profession.”
But improving leadership and repositioning nursing will take time. “It’s hard to change a profession,” says Hammond. “There aren’t any clear, evident changes that can be made right away, certainly none that could be made at a low cost at the institutions that employ nurses--or they would have already done them. The issue is stickier than that. It’s going to take time to reconfigure the way we think about nursing.”
Better compensation for nursing expertise
For administrators’ grappling with the current shortfall, recruiting and retaining nurses is an urgent matter. Some hospitals are offering signing bonuses and salary increases as a way to attract nurses. While such incentives can aid recruitment, their use needs to be carefully considered.
“Signing bonuses can create organizational issues because they create differentiation in hiring practices for people responsible for the same job,” notes Hammond. “One of the stresses in nursing is the status differentiation between doctors and nurses. When you add to that a differentiation in hiring practices, the current nursing pool, who already feel overworked and under paid, begin to feel a little bit rained on.”
Furthermore, there is no evidence that signing bonuses help retain nurses. “Signing bonuses create a mindset where you stay in a place for a year and then you go somewhere else and get another one,” says Robbin Moore, an executive MBA graduate of Goizueta who is a nurse and the current CEO of Northlake Medical Center in Atlanta, Georgia. “You want to build the best nurses and retain them—not just recruit them. Signing bonuses don’t help you develop the best of the best nurses.”
In terms of salaries, nursing has seen a decline in terms of relative earnings. While actual earnings for RNs increased from 1983 through 2000, “real” earnings (adjusted for inflation) have been flat for over a decade. According to the Bureau of Labor Statistics, the average salary for RNs in 2001 was just over $41,000.
Additionally, salaries appear to compress over time; that is, increases in salary occur early in nursing careers and taper off with time. “Every time we’ve moved into a shortage, they raise the entry salaries and then they compress so that the more experienced nurses can’t go anywhere,” notes Salmon. “There is a lot of bad compensation policy that could be corrected and would cost less than the cost of temporary agencies and signing and recruitment bonuses.”
Improved work environment and monetary compensation has led some nurses to consider unionizing. But experts at Goizueta and Emory contend that the bottom line issues still revolve around leadership and effectively empowering the workforce.
“If you treat your people properly and they have sustainable working schedules and a good work environment, you could invite a union to come on in and tell it to ‘Help Itself.’ But if I’m taking care of my people better than a union can take care of them, a union won’t take. If you’re not, you’re susceptible,” observes Hill.
“To me a union is there because you earned it,” says Salmon. “Hospital CEOs need to understand that nurses are first and foremost an investment in the quality of their enterprise—and ultimately in the cost, but they’re not the cost,” contends Salmon. “If you look at nurses as an investment, you will treat them differently.”
Recruiting nurses from abroad
The need for nurses has led some hospitals to look abroad for answers. Joseph Borocz, a Goizueta MBA graduate, is the co-founder of AmericaPlus, a nurse recruitment company that currently recruits qualified nurses who are fluent in English from Romania and Hungary.
Although the nursing shortage is global in scale and Hungary itself suffers from a nursing shortage, Borocz believes there are several positives that come from importing nurses. “Since we recruit from culturally sophisticated European countries, the nurses generally come for a period of 1 to 3 years and then return home to their families,” observes Borocz. “They are learning and then taking new skills and improved procedures to their home countries, which in turn will improve the healthcare system in Central Europe. In addition, the money they saved will enable them to make that initial down payment to start their lives, thus helping the overall economy.”
Salmon, who has chaired a global advisory committee for the World Health Organization and who currently sits on a think tank about the immigration of nurses, believes it’s a very complex issue. “Countries such as the Philippines and India have made an industry out of exporting nurses, and are very sophisticated about how they do it,” she says. “One thing of which I am very aware is that the countries that need the nurses the most are the ones we’re importing from…. I think there are fundamental public safety issues and I believe we owe it to ourselves and to the world to take care of our problem.”
Nursing’s future: the “hope generation”
Salmon is encouraged by the quality of the 94 students who entered the doors of the Woodruff school this fall and by the returning students she collectively calls, “The Hope Generation.”
“These young people saw a lot of bubbles burst in their developmental years: the tech bubble, the sense of safety and supremacy we thought we had as a country. I think a lot of them have been acculturated to reach out to one another and they see value as transcending the job you have or the money that you make,” she says.
“I see a generation that, while altruistic, is also realistic and a generation that can cross boundaries, that has learned as teams. We’re seeing both men and women entering the profession. We’re seeing women who have been involved in competitive sports and who didn’t grow up in an isolated context. We’re seeing men who don’t have hang ups about being male and being a nurse. I’m hopeful that this generation will be able to recast care by virtue of what they bring even before they enter the program here at Emory.”