In Focus: What Do the Numbers Say?

HealthBond - Anne Marie Talbott, MA, MBA

What Do the Numbers Say? Research on the Nursing Shortage Problem

The American Organization of Nursing Executives (AONE), in conjunction with the ANA, completed a survey of 388 acute care hospitals. Their results indicated a nursing shortage is in existence, but a different kind of shortage than those seen in the past. This shortage is different, the researchers say, because healthcare facilities are having a hard time finding qualified, competent nursing staff for their acute care facilities. The nursing staffs currently working are overworked, underpaid and stressed. This propels many qualified, caring nurses to leave the acute care setting for less stressful working areas, including leaving nursing entirely.

The findings of the AONE and ANA study indicate that nursing education needs to become more targeted, focusing on these areas, and on developing the educational abilities in nursing students that are necessary to pass qualification exams. The healthcare facilities, acute care settings as well as other medical settings, are competing with each other to attract these qualified personnel, which can increase the benefits offered to their recruits.

The top three concerns stressed by the respondents in the national survey are:

1. "finding nurses with appropriate skills, competency and experience, stemming in part from the lack of educational resources to keep nurses up-to-date and a deficiency in nurse education programs with lack of real world experience prior to joining hospital staffs

2. managing flexible staffing to accommodate the fluctuating patient census and the use of temporary staffing

3. organizational issues including increased paperwork and decreased financial support for nursing management support systems." (Research on Nursing Staff Shortages, presented to the AONE, November, 1998, by the HSM Group, Ltd.)

Urban hospitals are having a harder time recruiting and maintaining qualified nursing staff, which may or may not be an emerging trend. But they were reporting significantly more problems filling nursing staff vacancies in the last three months of 1998, and that trend appears to continue today.

However, rural hospitals were reporting, at the same time, that their searches for qualified nursing staff were stretching longer and longer. Nursing staff currently employed were becoming more resistant to working flexible schedules and shift schedules, too.

Agency and contract nursing services are being used more often by larger and urban healthcare facilities, the study noted. What does that mean for the independent nursing staff, or the nurse who's just graduated from school? Working through a contracting group or an agency may not be the best choice for many nursing staff, but in times of shortage, as these appear to be, it may be the way to get in the door.

Retention is a major issue. Why is it so hard to keep well-trained, highly qualified staff, once you've got them? Many reasons: lack of leadership models, stress in the workplace, burn out, lack of advancement opportunities, lack of educational support for advancement and other facilities offering better working hours and benefits. These are all areas that need to be addressed by hospital management and nursing staff, as well as nursing educators. Some are just part of the workplace experience for medical staff, but with proper management and support, a stressful workplace need not be a major cause for retention failure.

The perception among many nurses that support is lacking in clinical and management areas is leading to shortages within clinical specialty areas and nursing executive/management areas. Again, here management plays a key role. Management can help change the perceptions shared by nurses wanting to be clinical specialists or executives/managers. Is it? Or is management too focused on meeting the bottom line, making the spreadsheets balance?

The dissatisfaction among nurses is spreading to other healthcare members--other nursing staff, technicians, and physicians--and this has to have an impact on acute care and patients. How can we intervene, as managers, nurses, doctors, techs? How do the patients feel about this? Is this being addressed in nursing education programs? How prepared are nurses coming out of degree programs for the stresses, like the ones mentioned above, in the modern acute care setting?

The top three critical priorities in nursing staffing, from the AONE and ANA study, were, in order: finding nurses with appropriate skills, competency and experience; scheduling staffing practices, and patient-to-nurse ratio and quality of care. Of these, the recruitment of qualified nursing staff seems to be the most critical to the 388 study respondents. However, is this part of the nursing shortage problem, or an on-going recruitment and staffing problem?

  • Many of the respondents indicated that their difficulties in finding qualified nursing staff seemed to stem from weaknesses in nursing training programs: "...in school, they learn more theory and less clinical. They are depending on the hospital to give hands-on training. I've had grads who have never started an IV." (Research on Nursing Staff Shortages)

  • Some of the study respondents were concerned about flexible staffing requirements. With fewer nurses, staffing has been forced into flexible staffing and shift scheduling that does seem to stretch the medical staff's ability. "...many of the shortages we create ourselves. We make decisions to deliver a certain care delivery model or to open more beds without considerations of what the market will support, and without adequate planning to ensure you are going to have the staff in place." (Research on Nursing Staff Shortages)


    Many in the study seemed to see systemic problems, not just an acute problem with nursing shortages as the symptom. The overall problem seems to be more deeply embedded in the healthcare system, and several respondents replied specifically to that, in the AONE and ANA study.

  • "...in a very schizophrenic mode in their desire to provide quality care with increasing paperwork and decreases in educational and financial resources. If you ask people to do more with less, you will get less." (Research on Nursing Staff Shortages)

  • "...corporate hospitals are burning hospital nurses out. This is such hard work, and they are leaving the profession now. People don't always have to work now, why should they put up with this?" (Research on Nursing Staff Shortages)

  • "...it's almost down to quantity and quality. We are spread thin, and it's critical to have sufficient numbers of RNs on duty who can do more and handle more." (Research on Nursing Staff Shortages)

    What is the role of management in this process? So far, it seems to have taken the route of short-term fixes, not looking at the overall problem for nursing staff and management. There may be a nursing shortage, certainly there is a shortage in specialty areas, specifically, but if management doesn't change its current mindset, there will be a larger crisis in the field, as the shortage of qualified, competent staff spreads.

    How do we solve the nursing shortage crisis? First, define it. Is it a shortage of nursing staff in general, or is it more focused on specialists? Is nursing management in crisis, too? Once we have it clearly defined, then we can look at curing the overall problem, not just band-aiding the symptoms. Bonuses and other perks only go so far. We have to look further, in more detail, at how to maintain support for nursing and other healthcare staff. It's a high stress job; burn out may be part of the job stress, but with proper management, guidance, and training in nursing education programs beforehand, a lot of that stress can be placed in its proper perspective.

    Workplace stress isn't the main issue. Leadership, and a coherent vision of the future of nursing, is the main point (in this writer's opinion). Yes, there are many problems with staffing, and burn out, and qualifications, but the main issue seems to be lack of vision across the board.

    If nursing staff can be feel part of the process, part of the solution, then they will be more invested in seeing that solution come to be. If they can feel part of the process of management, of being leaders, then they'll be more likely to work with management to achieve common goals.

    Hospital administrators, managers: right now, ask yourself: are the nursing staff you know part of the management? Part of the leadership? How can you empower them? If you don't know, you should find out, before your competition does, and your nursing staff leave your facility for better conditions elsewhere.

    If you're a nurse, or a nurse educator, ask yourself: how can I be a role model for other nurses? How can I be part of the leadership, able to make an impact on policy and management decisions, not just reacting, but being proactive? How much do I know about management? How can I increase my management skills?

    Dealing with the symptoms one-by-one isn't a prescription for wellness. Looking at the overall lifestyle picture can help create a healthier system. Nurses and managers need to work together to create a vision of the well system, and work together to push the system that's puttering along now towards that healthier version.

    Once that starts, some of the nursing shortage problems will be alleviated. There will always be issues around finding competent, caring staff, but if there's a coherent vision, a management plan, towards achieving and maintaining a healthy nursing staffing situation, maybe the problem won't be critical. Any ideas?

    In Focus for June, Nursing Shortage. Previous articles for June.

    June 5-9, 2000, Nursing Shortage: Mirage or Menace?

    Previous In Focus Series.

    Anne Marie Talbott, atalbott@healthbond.com