By Edward H. O'Neil, Ph.D, MPA, FAAN

Between now and the year 2020 the US health care system will face a number of critical challenges if it is to successful meet the demands of creating a safe, high quality, affordable system of care which is generally accessible to everyone. Perhaps the most significant of these challenges will be the provision of an adequate supply of appropriately trained health care professionals. The most dramatic of these shortfalls will occur in nursing. One federal estimate has the gap between supply and need being as great as 800,000 over the next fifteen years.

The causes of this situation are varied with some of them being specific to nursing some generically impacting all of health care and some being the labor market pressures of a modern economy with a stable population competing for talent. About 95% of nurses are women. For many years nursing and teaching were the principle professional occupations open to women, but as that has changed and women have found other professional work available to them, men have not moved in to make up the difference in demand for new entrants. The profession, particularly, the hospital based work, which still makes up about 60% of nursing practice, has been beset by labor actions, lay-offs and shortages, making it unattractive to many potential entrants and even to those that have finished training, but find working in such an environment unappealing. Many of these have exited in-patient service or the profession as a whole. Nursing wages have not, until recently kept pace with those with similar training, and there is little opportunity for upward mobility within the clinical practice of the profession.

Like all clinical education, nursing is expensive and the growth of new educational capacity to meet student demands has been slow or nonexistent. Nursing and allied health programs have a great dependence on state budgets and even when state policy makers recognize the need for growth, funds have been needed in other areas more critically. Perhaps the greatest driver of workforce shortage to be experience by all professions is the care needs of the aging “Baby Boomer” population paired with the projected retirements of health professionals from the same generation. This confluence will produce the second wave of the health professional crisis, which really won’t be felt until after 2010 and as Boomers go on to Medicare and reach and age at which the physical demands of practice make it no longer sustainable.

Finally, the nursing crisis shares some characteristics with all parts of the
U.S. labor market. As population growth slows there will be fewer and fewer native born workers for all positions. This will mean greater competition for those and the necessity for all sectors to attract and sustain foreign born workers. Such workers are already an important part of the US health care workforce. Two ethnic groups are also underrepresented in nursing, African-American and Latino, and recruiting them into the profession represents both a challenge and an opportunity. Regardless if native born or immigrant, the health care system will be able to meet its needs for a high quality and productive system only if it is able to attract the best and the brightest to the nursing profession. As technology changes at a faster pace, customer expectations grow, and the need of innovation and adaptation continue health care organizations will need highly skilled nurses that can continue to grow and learn. If they are recruiting from the least desirable of potential workers they will have no hope of meeting these goals.

In spite of gloomy forecasts there is some encouraging news for nursing. The number of U.S. graduates taking the nursing licensing exam fell from about 96,610 in 1995 to 68,759 in 2000. Strong demand has led to a recovery to 87,177 in 2004, but there are still about 100,000 nurses that should have been trained during that decade that are missing from the profession. The wage rates for the profession have increased beyond comparable professions and there is more opportunity for work. There are also new partnerships between care delivery systems and education which have identified new resources and enlarged clinical training capacity. However, even with these resources, there is a growing shortage of faculty, many of whom now make more in practice than as teachers.

To address the nursing crisis care delivery systems need to consider several strategies. First, concerted efforts must be made to make the work environment attractive. Pay is one element of this, but not the most important. Nurses find those work environments which value their professional contributions, involve them in decision making, crate opportunities for nursing research and build collaborative and supportive structures to be the most attractive. The lessons from the Magnet Hospital experience can be readily translated here to any care delivery or service setting. Next, care delivery organizations must develop deeper ties and partnerships to nursing education. To be successful, this must go beyond just sharing clinical training and support and should include research, curriculum decision making, and resource sharing. Third, care delivery organizations need to make the case with political leadership that nursing and health professional employment is not a problem, but a jobs development opportunity. Half of the fastest growing jobs in the next decade will be in health care and life sciences and few jurisdictions will have attractive employment situations unless they master this. This is particularly important for the two key under represented groups discussed above.

The work force crisis is real and will not soon go away. Safety net institutions may perceive that their plight will be even more difficult than other institutions in care delivery. A study by the Center for the Health Professions at the University of California, San Francisco has found that their challenges will be different but not across the board more difficult as they recruit health professionals, including nurses. Safety net institutions may have more constrained resources and can be less generous with compensation and benefits. Public delivery institutions may be more bureaucratic and less nimble in their response. But, safety net institutions of all type were perceived as more focused on the high value work of serving those in need, more stable than market driven health care and more likely to be managed and led to serve a mission, not meet a bottom line. These factors made safety net institutions more attractive to many. The nature of the mission driven work meant that once the employ made it past their first year and a half they were likely to stay for the duration of a career.

These are significant strategic advantages which, with attention from leaders in safety net institutions, can be used to address many of the coming challenges created by shortages in nursing and other health care workers.

Edward O'Neil (Ph.D.) is Professor of Family and Community Medicine and Dental Public Health at the University of California, San Francisco. He also serves as the Director of the Center for the Health Professions, a research, advocacy and training institute created to assist health care professionals, health professions schools, care delivery organizations and public policymakers respond to the challenges of educating and managing a health care workforce capable of improving the health and well being of people and their communities. Dr. O'Neil is the Principal Investigator for the Pew Scholars and Latin American Fellows Programs in the Biomedical Sciences, the Robert Wood Johnson Executive Nurse Fellows Program, the California Workforce Initiative and the Future Leaders Program, funded by the California HealthCare Foundation.