North America is experiencing a nursing shortage that threatens to worsen considerably over the next 10 years. Given all the studies of nursing practice settings published over the past 25 years, it seems reasonable to expect that we would have learned lessons to help us avoid yet another crisis in recruit- ment and retention. For a number of reasons, this hasn’t happened. First among those is the reality that, as health economist Robert Evans has said so simply, “policy is possible.” Policy decisions taken in the 1990s to reduce the number of nursing graduates had their intended effect. Between 1990 and 2000, the number of registered nurse (RN) graduates dropped by some 40% at the same time as Canada’s population increased by 15%. There were actually less RN graduates in 2000 than in the mid- 1960s, and, of course, the existing nursing workforce continued to age and move toward retirement. Over just a decade, the balance has shifted such that the number of exits from nursing exceeds the number of new nurses coming into the profession even when we include nurses who migrate to work in Canada. So the appearance of shortages of nursing services in the early part of this century is a result of deliberate policy choices; it is not a mystery.
Shortages
So, what to do about shortages that are now before us? The actions taken to address historical “boom and bust” cycles of nursing shortages and surpluses have too often been short-sighted, providing interim relief but long-term residue. During the shortage of the 1980s, many organizations introduced unregulated healthcare workers to deliver some aspects of patient care. Research now shows that patient care outcomes may have been negatively affected by this decision (McGillis Hall et al., 2001). Alternately in Canada, during the period of fiscal restraint and healthcare system restructuring of the mid-1990s, thousands of nurses across the country were laid off or encouraged to accept offers of early retirement. Thousands more underwent job changes in the “bumping” that followed. In Quebec, the government-appointed Clair Commission concluded that these departures and changes contributed to weakening the level of expertise within the system and negatively affected team environments (Commission d’étude sur les services de santé et les services sociaux, 2000). The short-term solutions in both of these circumstances had long-range consequences that were not anticipated—and might have been avoided.
It is not a sufficient excuse that healthcare leaders and policymakers did not know, or could not have predicted, what the long-term consequences of these decisions might be. Research suggesting a correlation between levels of RN staffing and patient morbidity and mortality had begun to emerge well before many of the policy decisions impacting patients and nurses were taken in the 1990s (Aiken, Smith, & Lake, 1994; Hartz et al., 1989; Knaus et al., 1986; Prescott, 1993).
Second, policymakers, managers, and others have generally done an inconsistent job of translat- ing research into actions. Despite increasingly robust research defining what nurses need to optimize the effectiveness of their work environments and to balance that with the demands of their personal lives, nurses have not always been very effective at influencing those who make the decisions that affect their practice.
Kimball and O’Neil (2001) suggest that several major developments have contributed to the unique and overwhelming nature of the current nursing crisis: a changing demography, a changing healthcare system, changing social values, and an alteration in the nature of work. They indicate that the size and complexity of these changes are so significant that strategies to deal with past nursing shortages will be inadequate for today’s crisis. Recent evidence suggests that Canada’s looming short- age threatens to rival only that of the United States as the worst of all the member nations of the Organization for Economic Cooperation and Development (OECD, 2004), and most of the member countries report worrying shortages. By about 2011 in the United States, for example, as the popula- tion continues to grow, the number of new RN licenses issued will, for the first time, be less than the
number of retirees. By 2016, the RN shortage in Canada is predicted to be in the 30% range unless drastic countermeasures are taken immediately and are sustained over the next decade. Furthermore, the OECD work gives every indication that the demand for nursing services will continue to grow.
Actions to Ameliorate Shortages
Kimball and O’Neil (2001) describe a continuum of the kinds of actions needed to address shortages in the nursing workforce. They make a convincing case that for long-lasting, positive impact, solutions that use and respect the nurse as a valued asset and professional partner will be most effective. The four kinds, or stages, of actions follow.
STAGE 1: SCRAMBLE
In the early stage of a workforce shortage, there is a “scramble”—a flurry of short-term actions that are unilaterally initiated by providers of care. Examples include colorful recruitment brochures, inter- national headhunting visits, sign-on bonuses, accelerated placement on the wage scale, and other activities focused on monetary incentives. These kinds of actions treat the nurse as a commodity that will respond to traditional market incentives. In the scramble stage, little attention is paid to changing nursing education, the nature of work, or the structure of the profession.
STAGE 2: IMPROVE
Once the reality and the seriousness of the shortage are clear, employers begin to recognize that nurses have particular wants and needs, after which the employers begin to approach nurses as customers. Interventions focus on increasing choice, reducing stress, and improving safety. Examples of improve- stage responses are improved clinical experiences in nursing programs, scholarships and loans, Internet-based distance learning, flexible benefits and scheduling, and preceptorship and mentorship programs—activities designed to make longer-term investments in people to cultivate their loyalty. In this stage, there is still minimal structural change to the professional aspects of nursing.
STAGE 3: REINVENT
As the challenge of providing high-quality care with fewer professional nurses continues to mount, it becomes clear that there is a need to rethink the ways professional nurses are recruited and trained, how they are integrated into the system, and how they are challenged and rewarded. In the reinvent stage, new roles are developed that blur the traditional boundaries between nursing roles. Examples of reinvent-stage responses include shared governance models, specialty internships, the adoption of magnet hospital values, and incentive rewards for sustained clinical outcomes improvement. The role of the professional nurse in the delivery of high-quality, patient-centered care is not only recognized but also leveraged by the employer as a valued asset. The employer, in turn, is rewarded with improved patient clinical outcomes and satisfaction.
STAGE 4: START OVER
At the far end of the response continuum are interventions in which nurses are viewed as professional partners practising at the upper limits of their professional licenses and respected by consumers as patient advocates, information resources, and teachers and supporters of self-care. Examples of start- over actions include new systems of care delivery and professional practice that cross traditional care boundaries such as academic nursing schools’ establishment of community-based, primary-care clin- ics staffed by nurse practitioners.
Because this chapter is written in 2008, it would be difficult to say that nursing finds itself firmly in any of these stages. A decade into the shortage predicted by the late 1990s, we see mixed signals. Certainly there were indications of “scramble” and “improvement” actions over the past decade. For example, we have seen improvement mechanisms put into place that do make aspects of working life
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more tolerable for some nurses. But we have not moved to a serious rethinking of the way nurses are educated, integrated, and utilized. What evidence before us would indicate that the roles of professional nurses in the delivery of high-quality, patient-centered care “are not only recognized but also leveraged by the employer as a valued asset?” In fact, responding to the seriousness of the shortage and apparent inertia of response, some nurse leaders seem to have moved past Stage 3 altogether, suggesting that what is warranted is a revolutionary rethinking of the healthcare system and the ways the nurses in it will be educated, employed, deployed, and regulated (see, for example, Villeneuve & MacDonald, 2006).
Regardless of what theoretical stage of response we might be in, a key question is this: How can nursing recruitment and retention be managed in a more predictable, thoughtful, and stable fashion than in the past? In particular, how can policymakers move beyond short-term, knee-jerk scramble and improve strategies to longer-term reinvent and start-over strategies?
This shift will require more deliberate and more carefully managed approaches to the problem, with policy being the key that unlocks the door to these higher-level solutions; it is only with the intro- duction of significant, broad-based policy change that substantive solutions will have staying power. If nurses want to successfully influence the formulation of appropriate and relevant policy, they must learn to utilize the levers outlined on page 80.