the vanishing nurse and other disappearing healthcare...

THE

VanishingNurse

...and OtherDisappearing

HealthcareWorkers

AF

T

HE

AL

TH

CA

RE

“It is ludricrous to recruit

people into a profession,

prepare them to uphold

its standards and then

make their work

environment so poor that

it sends them running

from that profession at

high speed. Yet that is

what is happening in

nursing today.”

SANDRA FELDMANAFT President

LASSIFIED ADS in major newspapers in this country arefilled every week with pleas for registered nurses

(RNs), licensed practical nurses (LPNs), physical ther-apists, lab techs, pharmacists and an array of other workersto accept jobs in hospitals, long-term care facilities, and homehealth agencies. Some employers offer signing bonuses worththousands of dollars. Others promise vacations or other perks.

There is no shortage of jobs available. The American Hos-pital Association reports that hospitals across the countryhave an average 11 percent vacancy rate for RNs. Some statesare harder hit than others. Various state hospital organiza-tions report vacancy rates as high as 20 percent in California,16 percent in Florida and 14.7 percent in Maryland to as lowas 6 percent in Wisconsin.

Vacancy rates in non-nursing fields also are soaring. Forexample, there is a projected national shortage of 46 percentfor respiratory therapists, and 64percent of hospitals say theyhave inadequate numbers of qualified lab workers.

Part of the problem is a turnover rate that has spiraled outof control. For example, the Hospital and Healthcare Com-pensation Service reports that hospital nursing staff turnoverrates rose from 11.7 percent in 1998 to 26.2 percent in 2000.Other organizations report a 51 percent turnover rate in nurs-ing homes and 21 percent for nurses working in home health-care agencies. For aides and lower-paid workers, that num-ber is far higher.

FOREWORD

C

T H E VA N I S H I N G N U R S E 1

2 T H E VA N I S H I N G N U R S E

Certainly, every employer is scrambling to fill vacancies.Gimmicks like bonuses and vacations may recruit a handfulof workers, but they will do nothing to address the long-termshortage this country is facing. Unless major initiatives areundertaken to address the shortfall of healthcare workers,this country will find itself lacking tens of thousands of neededemployees, and a true healthcare crisis will be at hand.

HE CURRENT NURSE SHORTAGE is exacerbated by short-ages in other healthcare professions. When there are

too few pharmacists, aides and lab techs, nurses havean even more difficult time providing safe, appropriate care,and the nurse shortage that exists seems even worse than itactually is.

There have been nurse shortages in the past. Some wouldeven say they are cyclical in nature. Past shortages, however,were largely the result of fluctuations in the economy and eas-ily remedied with increased salaries and improved benefits.Wages continue to be a factor in the current shortage. Forexample, nurses’ wages have been stagnant for some time.Comparing today’s wage rates to those of five years ago, RNshave seen an increase of only 0.8 percent, while real wages forthe general workforce have risen 6.6 percent. Going back evenfurther, and again adjusting for inflation, today’s wages forthe general workforce are 6.8 percent higher than in 1990,while real median weekly earnings for RNs fell by 0.7 percentin the same period.

The current shortage involves every type of healthcareworker, and it appears to lack an easy solution. Many factorsare at play:

An increased demand for nurses. As 78 million babyboomers reach retirement age, there is a resulting increase inthe demand for healthcare. The Bureau of Labor Statistics(BLS) predicts that the increased demand for nursing serv-ices combined with aging retiring nurses and a decrease inthose entering the profession will result in a shortfall of 480,000RNs by the year 2008. A national survey of RNs commissioned


T

WHY THIS SHORTAGE IS DIFFERENT


by AFT Healthcare in 2001 reveals, however, that unless changesare made where nurses work, the potential nurse shortagecould be much more severe than anyone has predicted.

A shrinking experienced workforce as nurses retire.

The 2000 National Sample Survey of Registered Nurses con-ducted by the U.S. Department of Health and Human Ser-vices reports that the average age of the RN population was45.2 years, up from 36.3 in 1980. Younger people, often referredto as Generation Xers, are looking past nursing and otherhealthcare professions and toward more technology-basedcareers.

A lack of new nurses entering the field. At the sametime more and more nurses are retiring, the American Asso-ciation of Colleges of Nursing reports that students enteringbaccalaureate nursing programs fell almost 21 percent between1995 and 2000.

Nursing as a profession is stubbornly homogenous.

Although the number of men entering nursing increased 62.3percent between 1992 and 2000, men still account for only7.2 percent of all working RNs. Men also make up only 8.6 per-cent of occupational therapists and 37.6 percent of respira-tory therapists. Similarly, the vast majority of all healthcareworkers are white, including 84.3 percent of RNs, 92.7 per-cent of occupational therapists and 87.2 percent of respira-tory therapists. Clearly, making these professions more attrac-tive to men and minorities would help alleviate shortages.

ETERMINING THAT RETENTION of current nurses isat least as important as recruiting new nurses into

the profession, AFT Healthcare commissioned PeterD. Hart Research Associates to conduct a national telephonesurvey of registered nurses in the spring of 2001. Interviewedwere 700 current direct-care nurses and 207 former direct-care nurses who continue to have a nursing license but nolonger provide patient care.

Both surveys were conducted among national samples thatcame from a list of RNs purchased from a private company.The national database from which the names were selectedwas compiled from state licensing information and is updatedquarterly. Both union and non-union nurses were surveyed.

No Debate: There’s a Shortage

This study was undertaken to understand the dynamicsand attitudes underlying the worsening nurse shortage in theUnited States, particularly in the field of direct patient care.The first step was to look at the extent to which nurses whoare currently in this field, or who were in this field in the past,actually believe that there is a nurse shortage and a problemwith retaining qualified nurses in the field.


D

THE AFT HEALTHCARE SURVEY:

Problem Will Be Worse than Expected, But There Are Solutions

Nearly all current nurses (89 percent) believe that there isa shortage of registered nurses who provide direct patient carein their local area, including 45 percent who think the short-age is severe. Recognition of a nurse shortage is consistentacross the four regions of the country, and nurses in privatehealthcare facilities (45 percent) are just as likely as those inpublic facilities (45 percent) to feel that there is a severe short-age. Nurses working in hospitals (48 percent) recognize theshortage as more severe than do those in clinics (36 percent).

Former direct care nurses are just as likely to recognize thatthere is a nurse shortage in their local area, with 48 percentwho qualify it as severe. Former nurses age 50 to 64 (57 per-cent) perceive the shortage to be more severe than do theiryounger colleagues (40 percent).


Universal RecognitionOf A Nurse Shortage

45%

39%

14%2%

Current Nurses

Severeshortage

Moderateshortage

Minor/noshortage

NS

84%

Among former nurses, 48% say there is a severe shortage, 38% saymoderate shortage, and 10% say minor/no shortage.

FIG. 1


Recruitment and Retention Are Problems

Current and former nurses both think that retaining andrecruiting qualified nurses are significant problems. Seven in10 current nurses say that their facility has a major or mod-erate problem retaining (70 percent) and recruiting (69 per-cent) qualified nurses. Former direct care nurses are evenmore apt to think that healthcare facilities in their local areahave a problem retaining (81 percent) and recruiting quali-fied nurses.

A closer analysis of current nurses’ perceptions regardingretention reveals that younger and less-experienced nursesare among those most likely to perceive retention as a majorproblem. Among current nurses age 50 and over (40 percent)and among those who have been in the field for more than 10years (41 percent), two in five think that retention is a majorproblem for their facility, whereas 48 percent of those age 18to 39 and 50 percent of current nurses with 10 years’ experi-ence or less in the field recognize it as a major problem.

Retention appears to be an especially severe problem forhospitals, where 47 percent of current nurses acknowledge it

Problems With RetentionWidely Recognized

Major problem Moderate problem

Retaining qualified nurses:

Current nurses

Hospital

Clinic

Other

Former nurses

70%

74%

62%

63%

81%

FIG. 2

as a major problem for their healthcare facility, whereas 36percent of nurses in clinics and 33 percent of those in othertypes of healthcare facilities agree. Current nurses working inthe South (53 percent) also indicate that retention is a muchgreater problem there than do their counterparts in otherregions of the country (43 percent West, 39 percent North-east, 38 percent Midwest).

Former nurses, older nurses and those who ceased pro-viding direct patient care fairly recently think that retentionand recruitment are bigger problems than do younger nursesand those who left the field more than four years ago. Thesedifferences may indicate that, in recent years, conditions haveworsened and problems facing nurses have grown more severe.

One In Five Plan To Leave

The most startling results of the survey came from thosenurses currently providing direct patient care. One out of everytwo current nurses said that in the past two years they haveconsidered leaving the patient care field for reasons otherthan retirement.

More alarming is that one in five (21 percent) said they willleave the profession within five years for reasons other thanretirement. This is in addition to the nurses who plan to leave


Most Believe The Situation FacingRNs Has Been Getting Worse

9%

26%

63%

4%

18%

78%

Getting better Staying about the same Getting worse

All Current Nurses

The overall situation for registered nurses has been . . .

Potential Leavers

Former nurses: 5% better

15% same 77% worse

FIG. 3


as they reach retirement age. This situation has not been con-sidered by government agencies like the Bureau of Labor Sta-tistics (BLS), which has predicted a shortfall of almost a half-million RNs by 2008.

These “potential leavers” overwhelmingly believe thatthings are getting worse for nurses and are extremely dissat-isfied with their profession and their current work situation.Certainly if their work environments do not drastically improvein the very near future, we could be looking at a shortfall ofsome 1 million RNs in the next five to seven years, a predica-ment that will result in access to care for only the most acutelyill patients and an even worsening work environment for thoseRNs who remain in the direct care arena.

Current nurses also report a low level of morale among reg-istered nurses at their healthcare facility, with only 31 percentrating morale as excellent (5 percent) or good (26 percent)and 68 percent who say it is fair (42 percent) or poor (26 per-cent). Current nurses who relay the lowest levels of morale attheir healthcare facility are also the ones who perceive thegreatest decline in the situation facing nurses in recent years:

And Morale Is Low

Excellent Good

Poor Fair

All Current Nurses

How is the morale among RNs where you work?

Potential Leavers

31%

18%

68%

81%

HospitalClinicOther

Excel/good25%43%46%

Fair/poor74%55%53%

All Current Nurses

FIG. 4

younger nurses, those who work part time, those workingnon-daytime shifts, and those from the Northeast.

As shown in FIG. 4, current nurses working in hospitals (25percent excellent/good, 74 percent fair/poor) perceive a muchlower level of morale among their colleagues than do thosewho work at clinics (43 percent, 55 percent) or other types ofhealthcare facilities (46 percent, 53 percent). Potential leaversalso provide a particularly negative assessment of the level ofmorale among nurses at their workplace, with fully 81 per-cent asserting that morale is fair or poor and a mere 18 per-cent who say it is excellent or good.

Even though potential leavers are unsatisfied with theircurrent working conditions, they still love nursing. In fact, 71percent of potential leavers said the most enjoyable aspect ofbeing a nurse is helping patients and their families (comparedwith 62 percent of all current direct patient care nurses). It isimperative to keep these committed healthcare profession-als at the bedside.


6%

7%

15%9%

13%10%

19%

15%

21%20%

71%

62%

All current nursesPotential leavers

Most Enjoyable AspectOf Being A Nurse

Helping patients andtheir families

Challenging/interestingresponsibilities

Working closely withpeople I like

Professional autonomyto make decisions

Continuously learningon the job

Earning a good salaryand benefits

FIG. 5


6%

7%

25%9%

20%11%

32%23%

31%

26%

11%35%

Left nursing four/fewer years ago

Left nursing at least five years ago

Reasons Former NursesHave Left Patient Care

Less stressful/physicallydemanding job

Regular hours/schedule

Advancement opptys

More money

Raise children

Fewer hours

POTENTIAL LEAVERS

■ 55 percent are just somewhat or not at all satisfied with their joboverall (compared with 38 percent of all current nurses).

■ 78 percent believe that the overallsituation facing nurses at theirfacility has been getting worse(compared with 63 percent of allcurrent nurses).

■ 81 percent rate the level of moraleamong RNs at their facility as fair orpoor (compared with 68 percent ofall current nurses).

■ 75 percent would pursue a careerother than nursing if just startingout (compared with 49 percent ofall current nurses).

FIG. 6

Stressful Working Conditions Drive Nurses Out

The 2000 National Nurse Survey reported that 20 percentof the nation’s 2.7 million RNs are not currently working asnurses. The AFT Healthcare survey found that most formernurses continue to be employed, and nearly all of those whoare employed use their nursing skills in their current job.

Of the former nurses surveyed, they were nearly evenlydivided between those who left direct patient care fewer thanfive years ago (48 percent) and those who left longer ago (52percent). Likewise, they were similar in age and other demo-graphic characteristics. That is where the similarities end.Former nurses who left patient care within the past four yearsdisplayed markedly different attitudes and levels of satisfac-tion with their nursing jobs than did former nurses whodeparted four or more years ago.

Specifically, former nurses who left more recently said theyleft patient care jobs for ones that were less stressful, less phys-ically demanding (35 percent) and with more regular hours(26 percent). Compared to former nurses who left nursing five


11%

14%

14%

18%

22%

56%

Reasons Nurses Have ConsideredLeaving Patient Care

Less stressful/physicallydemanding job

Regular hours/schedule

More money

Advancement opptys

Raise children

Fewer hours

(Among the 50% of current nurses who haveconsidered leaving for non-retirement reasons.)

FIG. 7

or more years ago where advancement opportunities, moreregular schedules and raising children were the most impor-tant reasons for leaving, those nurses who left more recentlydid so because of intolerable conditions in the workplace.

Comparing the reasons that current nurses consider leav-ing and the reasons that former nurses give for leaving patientcare within the past four years, it is obvious that stress andirregular work schedules continue to be the major culprits.More than half of current nurses (56 percent) said they con-sidered leaving patient care jobs for less stressful or physi-cally demanding jobs.

Staffing Levels Must Be Improved

When considering changes that could be made to retaincurrent nurses and to bring back into the profession nurseswho have left, it is important to look at the issues that nurseshave identified as problems. Without a doubt, inadequatestaffing levels top the list.

Less than satisfactory numbers of nursing staff began tobecome a problem in the early 1990s as healthcare becamemore financially competitive. Hospitals and other healthcareemployers began reducing nursing staff as a way to cut costs– either to increase profits or remain competitive for lucrativemanaged care contracts. At the same time, more and morepatients were being seen on an outpatient basis, leaving onlythe most acute patients in hospitals. Those very ill patientsdemanded more nursing care, not less. Fearful that they couldnot provide quality healthcare, nurses who remained in thehospitals began looking for other sources of employment. Now,some 10 years later, we find ourselves in the midst of a seriousnurse shortage that was created by the healthcare industryand can only be solved by changes within that same industry.

Nurses Would Come Back

Both current and former nurses agree that increased staffingwould do the most to improve their nursing jobs (43 percentof current nurses and 41 percent of former nurses). Even moreinteresting is that if the appropriate changes were made, almost


two out of three former nurses said they would consider re-entering direct patient care. Changes that would have to bemade include better pay (23 percent), better staffing (21 per-cent) and better, more flexible schedules (21 percent).

Perhaps more important, three in four (74 percent) “poten-tial leavers” said they would consider continuing in patientcare for longer if changes were made. What would make themstay? Increased staffing and better salaries top the list. Otherchanges that would make a difference are better hours andschedules, more respect, more of a voice and input into howthings are done, and more support from management.

There is some evidence beyond this survey that makingthese types of changes – especially in staffing levels – wouldresult in increased retention and more effective recruitment.For example, in Joshua Tree, Calif., Hi-Desert Medical Cen-ter, a 175-bed district community hospital, reduced its RN-to-patient ratio on med/surg floors to 1:4 on day shift and 1:5on second shift. “Almost immediately,” according to the hos-pital, nurses began applying for positions at the hospital. Thenurse vacancy rate dropped from 50 percent to less than 1percent in just a few months. The hospital, which had spentsome $800,000 on temporary nurses in 2000, said the newnurse-patient ratio has had an immediate effect on the moraleof the nurses employed there.

In the Australian State of Victoria, members of the Aus-tralian Nursing Federation (ANF) lobbied for minimum nursestaffing ratios. The ratios were mandated on August 31, 2000,with implementation beginning the following spring. Theratios vary depending on the size and location of the hospi-tal to meet the needs of nurses and patients. Since the ratioshave been implemented, the ANF reports that 2,300 nurseshave returned to nursing with additional nurses waiting tostart refresher or re-entry programs. ANF also reports thatturnover has decreased and morale is on the rise.



How To Improve RetentionAnd Recruitment

60%

61%

63%

69%

71%

76%

79%

81%

87%

Potential leavers who say each would be very effectivein recruiting/retaining quality nurses

Better staffing ratios

More patient time

Input in decisions

Raise salaries

Performance bonuses

Flexible schedules

More part-time options

Continuing education $$

Better health coverage

44%

47%

50%

50%

50%

52%

53%

54%

55%

56%Refresher courses

More aides/support staff

Summer leave option

Mentor new hires

Continuing educ time off

Orientation for new hires

Better retirement

More paid time off

On-premises child care

Performance-based salary

FIG. 8

IVEN THE RESULTS of this national survey, AFTHealthcare offers the following recommenda-

tions to help stem the shortage of nurses and other health-care professionals:

■ Develop federal standards for healthcare staffing levels inhospitals and other healthcare facilities. Healthcare employ-ers must be required to provide adequate staffing levels andskill mix to ensure quality care to patients and a safe workenvironment for caregivers.

■ Adopt a legislative ban on mandatory overtime. Healthcareproviders in every state should be protected from retaliationfor refusing mandatory overtime. Of course, if adequate staffinglevels are in place, mandatory overtime should become a prac-tice of the past.

■ Provide loan forgiveness and other incentives to draw peo-ple into healthcare professions. Enhanced recruitment effortsfocused on the economic aspects of healthcare training areessential if we hope to curb the exodus of healthcare profes-sionals as they change careers or retire.

■ Expand recruitment efforts targeted at men and minorities.Non-economic recruitment efforts must also be developed.

■ Offer healthcare workers higher salaries and better bene-fits, especially pensions. While working conditions have dete-riorated, so have wages and benefits. Healthcare employersgenerally spend less per employee on benefits – particularlyon pensions – than do employers in other industries.


G

RECOMMENDATIONS

Candice Owley, ChairPresident, Wisconsin FNHP

Ann Twomey, Vice ChairPresident, Health Professionals and Allied Employees

(HPAE)

Sylvia Barial

Chair, School Nurse Chapter, United Teachers of NewOrleans, Local 0527

Ora James Bouey

United University Professions, Local 2190

June Edwards

Public Employees Federation, Local 4053

Carol Flynn

Treasurer, Danbury HPNA, Local 5047

Anne Goldman

Special Representative, Federation of Nurses/UFT,Local 0002

Ralph Hickle

President, Healthcare-PSEA/FNHP, Local 5120

Jacqueline Himes

Executive Board Member, Philadelphia Federation ofTeachers, Local 0003

Debra Perry

President, Maryland FNHP, Local 5197

Kathy Petrin

President, Oregon FNHP, Local 5017

AFT HEALTHCARE PROGRAM AND POLICY COUNCIL

AFT HEALTHCAREA D I V I S I O N O F T H E A M E R I CA N F E D E R AT I O N O F T E AC H E R S

555 New Jersey Avenue, N.W.Washington, DC 20001

ASK FOR ITEM NUMBER 67-FN-0034

the vanishing nurse and other disappearing healthcare...

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