Sources: The National Sample Survey of Registered Nurses, March 2000, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services; The Current Population Survey, U.S. Bureau of the Census; Projected Supply, Demand and Shortages of Registered Nurses: 2000-2020, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services

Nursing Issues Research

Research Studies by ANA

ANA has conducted several data based studies (1997, 2000), as well as, several literature reviews (patient classification systems, relationship between nurse staffing and patient outcomes, etc.). The conduct of empirical studies is based upon the needs of the Association as related to emerging nursing issues. Literature reviews are conducted when the Association needs a better understanding of the extent of an issue, the breadth of opinion on an issue and/or the state of science in an area. Much of this research is conducted to support policy development.

• Nurse Staffing and Patient Outcomes In The Inpatient Hospital Setting
• Nursing Care Report Card For Acute Care
• Analysis of American Nurses Association Staffing Survey Staffing [PDF file], 2/06/01 Respondents cite reduced time for patient care, concern for patient safety.

It has been widely published nationally and internationally that there is a critical nursing shortage. Practicing RNs are desperately trying to gain control of their working environment. Many articles about high stress, and burnout about nurses have been published. Many choose to leave the profession and some choose to organize with trade unions. Proportionally, their union percentage is higher (19%) than that of the national average. (10%). When nurses work under a labor agreement they have more control over their hours, wages and working conditions.

Overview of Nursing Profession In the United States

1. More Nurses Are Needed
   • Registered nursing was among the fastest growing occupations in the 1990s. By 2003, the number of employed RNs was 2,449,000 - an increase of 31.7% since 1990.
   • For the first time, the U.S. Department of Labor identified "Registered Nurse" as the occupation expected to experience the largest job growth in the next 10 years. The need for RNs is predicted to continue to grow rapidly, rising by 27.3% between 2002 and 2012, compared to 14.8% during the same period for all occupations. More than 1.million openings for RNs are projected by 2012 due to growth and replacements.
   • There were 531,000 licensed practical or vocational nurses working in 2003 and their job prospects are expected to increase by 20.2% from 2002-2012.
2. The Nurse Work Force Is Aging and Changing
   • The vast majority of nurses are women, although the percentage of men in the field increased slightly in the last decade: the percentage of male RNs rose from 5.6% in 1993 to 7.9% in 2003, and the percentage of male LPN/LVNs fell slightly from 5.4%-5.2%.
   • Most nurses are white, although the percentage of minorities among nurses is increasing. From 1993-2003:
     • The black or African American share of RN positions increased from 8.4% to 9.9%. The proportion of black LPN/LVNs also increased from 17.2% to 22.3%. Blacks made up 10.7% of the total labor force in 2003.
     • The percentage of Latino RNs increased only slightly from 3.2% to 3.9% from 1993-2003. Latinos' share of LPN/LVN positions increased from 3.4% to 6.6%, while they made up 12.6% of the labor force in 2003.
   • The nurse population is aging since fewer people are entering the profession. The average age of RNs increased from 36 in 1980 to 45 in 2000. Over two-thirds of RNs are 40 or older. In 1992, 24% of RNs were between the ages of 25 and 34; by 2000, less than 16% of RNs were in that age group.
3. A Severe Shortage of Nurses Causes a Crisis
   • The U.S. is experiencing a severe nursing crisis that will intensify as baby boomers age and the need for health care grows. The Health Resources and Services Administration estimated nurse shortages in 30 states in 2000 and project the problem to expand to 44 states and the District of Columbia by 2020. Another study predicts a shortfall of 400,000 RNs by 2020. Factors involved in the shortage include insufficient new nursing school graduates, partly due to a serious shortage of nursing school faculty; an aging nurse population, and widespread burnout among nurses because of understaffing.
   • Understaffing: There are not enough nurses to do what needs to be done on any given shift and the nurses who are on duty are exhausted and stressed. A 2003 study by the Institute of Medicine (IOM) found the environment in which nurses work a breeding ground for medical errors, which will continue to threaten patient safety until substantially reformed. The IOM points to numerous studies showing that increased infections, bleeding and cardiac and respiratory failure are associated with inadequate numbers of nurses. A 2002 report by the Joint Commission on Accreditation of Healthcare Organizations called the nursing shortage "a prescription for danger" and found that a shortage of nurses contributed to nearly a quarter of the anticipated problems that result in death or injury to hospital patients.
4. Low Nurse-to-Patient Ratios: With managed care restructuring the health care industry in the 1990s, hospitals reduced staffing levels to lower costs. Nurses care for more patients and patients who are more acutely ill due to shorter hospital stays. One study of hospital staffing found that decreases in the number of LPN/LVNs added to RNs' patient load. Studies have linked low nurse-to-patient ratios to medical errors and to poorer patient outcomes, as well as to nurses leaving patient care. A 2002 study by Linda Aiken, et al., found that for each additional patient over four in an RN's workload, the risk of death increases by 7% for hospital patients. Patients in hospitals with eight patients per nurse have a 31% higher risk of dying than those in hospitals with four patients per nurse. The IOM study recommends that nurse-staffing levels be raised in all health care facilities.
5. Mandatory Overtime and Floating: Because of the nursing shortage, many hospitals routinely require nurses to work unplanned or mandatory overtime and to "float" to departments outside their expertise. On average, RNs work 8.5 weeks of overtime per year according to a recent union survey. Mandatory overtime was an issue in several recent strikes and 77% of RNs favor a law banning it except when an emergency is declared.
6. Burnout: Among nurses there are high rates of emotional exhaustion and job dissatisfaction which are strongly associated with inadequate staffing and low nurse-to-patient ratios. The Aiken study found each additional patient per nurse corresponds to a 23% increased risk of burnout, as well as a 15% increase in the risk of job dissatisfaction. A 2000 survey reported a satisfaction rate of just 69.5% among RNs, substantially lower than the 90% overall job satisfaction among professionals. This dissatisfaction is clearly linked to the departure of RNs from the nursing work force. In a survey conducted by the American Nurses Association, 33% of nurses under the age of 30 stated their intent to leave their present job within the year.
   • A study by Peter Hart & Associates found 50% of employed RNs had considered leaving patient care within the last two years for reasons other than retirement, and 21% of them said they expect to quit within five years. Nurses who are considering leaving patient care and those who have quit consistently cite better staffing levels and more time with patients as key to persuading them to stay or return to patient care.
   o Some nurses have left hospitals to work in less stressful environments. In 2000, an estimated 21% of all acute care hospital nurses left their positions.23 The proportion of RNs who work in hospitals fell from 66.5% in 1992 to 59% in 2000.
   • Healthcare employers are increasingly recruiting nurses from overseas, which allows them to avoid making fundamental changes to improve the quality of care, retain nurses, and make nursing an attractive career. The nursing crisis is an international problem: nurses' organizations from 69 countries and every geographic area reported a shortage of nurses. Overseas recruitment drains health care personnel from countries with more limited resources and health care personnel, and jeopardizes the well-being of their citizens. In Ghana, more than 500 nurses left the country in 2000 for higher paying jobs in richer countries - three times the total recorded in 1999 and more than twice the number of nursing graduates Ghana produced that year. Thirty-three countries - primarily in Oceania, Africa, Central America and the Caribbean - reported that the outflow of nurses to more affluent countries was a serious to extremely serious problem, which worsens the shortage that already exists. In addition, extensive use of temporary visa programs frequently depresses wages and guest workers themselves are particularly open to exploitation.
7. Nursing Is a Dangerous Occupation Nurses are at high risk of injury or illness due to occupational hazards.
   • Registered nursing is one of 12 jobs with the highest levels of occupational injury or illness requiring days away from work, with 21,900 cases reported in private industry in 2002.
   • In 2002, the non-fatal occupational injury and illness rate was 7.4 cases per 100 health care workers, compared to 4.6 per capita cases among workers in the service sector and 5.3 per capita cases in the private sector generally.
   • In a 2001 survey, the American Nurses Association (ANA) found that 40% of their members had been injured in the previous year, including needle sticks, but many had not reported the injuries.
8. Nurses Are Still Undervalued and Underpaid Nursing has historically been an undervalued and underpaid profession, considering the high level of education, skills and responsibility required of nurses.
   • RNs' wages have generally stagnated during the past ten years, particularly after 1994 when managed care restructured the health care industry and many nurses were laid off. In spite of the difficulty in retaining experienced nurses, employers have yet to raise nurses' salaries dramatically, as they did in the late 1980s in response to the last nurse shortage. Some employers have offered bonuses as incentives to attract new nurses to their hospitals, but this policy does not benefit experienced nurses or help to retain them.
   • RNs' average weekly wages fell by 6.2% from 1992 to 1997, while wages for the total labor market declined by only 1.2% during that period.
   • RNs' salaries regained some ground between 1997 and 2002, increasing 10.2% from 1997 to 2002, slightly ahead of those for the total labor force. RN wages also rose 3.8% from 2001 to 2003, from $849 in real wages to $881.
   • These gains only minimally offset the previous losses, as RNs' wages rose by only 3% from 1992 to 2002, while wages for the total labor force rose 6.8%.
   • LPN/LVNs' average weekly wages fell by less than 1% from 1992 to 1997. LPN/LVNs gained an 8% wage increase from 1997-2002, with a net result of 7.5% growth for the decade.
9. Benefits Are Poor but Increasing
   • Healthcare employers spend less on benefits than other non-manufacturing employers. Healthcare employers contributed only 6.7% of payroll costs to employees' pensions in 2002, compared to 9.6% spent by all non-manufacturing employers. For medical and medically-related benefits, the health care industry provided 6.6% of payroll, while all non-manufacturing employers spent 9.9%. The healthcare percentage is a significant increase from 2000, however when only 1.5% of payroll for healthcare employers surveyed went to employee pensions.
   • Because the nursing profession is overwhelmingly female, health care employers have justified lower benefits contributions by arguing that women tend to move in and out of the workforce and rely on their husbands' pensions and insurance. However, fewer women can count on a husband's benefits, both because fewer women are married and because more employers are reducing or eliminating coverage for workers and their families.
   • There are considerable variations in wages and benefits based on geographic region, full-time/part-time status, work setting, hospital characteristics and union/non-union status. [Union members have significantly better benefits)
10. Union Organizing Is Accelerating
    • Health care workers have been organizing in greater numbers since the mid 1990s. More than one in six of the 3,380 NLRB representation elections held in 2000 was held among workers in the health care industry. Workers in this industry were more likely to vote for a union than in industries in general: 60% for health care compared to 50% for all industries in 2000.
    • The number of representation elections in the health care industry increased by 47.7% between 1990 and 2000, while overall, there was a 6% decline in representation elections.
    • The size of the unit being organized has also increased. While in 1990 the average size was just under 100, in 2000, the average size was 132. As a result of increased organizing activity and larger units, the number of new members voting to join healthcare unions increased by more than 350% from 1990-2000.
    • In spite of these organizing wins, union membership and the percentage of nurses covered by bargaining contracts did not change significantly between 1993 and 2003.
    • Among RNs, union membership increased slightly between 1993 and 2003, from 16.1%-16.9%. Union density fell from 15.1% to 10.8% among LPN/LVNs.
    • The percentage of RNs represented by a union increased slightly from 19% in 1993 to 19.5% in 2003. For LPN/LVNs, union representation dropped from 16.2% to 12.4% in 2003; however, this is up from 8.7% in 2001.
    • Nurses covered by a union contract in 2003 earned nearly 14% more per week than non-covered nurses. Union RNs earned $984 per week on average, compared to $851 for nonunion RNs. LPN/LVNs belonging to unions earned $591 per week compared to $556 for nonunion LPN/LVNs.

Full Text

The Nursing Shortage: Perspectives from Current Direct Care Nurses and Former Direct Care ... ... DIRECT CARE NURSES AN OPINION RESEARCH STUDY CONDUCTED BY PETER D. HART RESEARCH ASSOCIATES ON BEHALF OF THE ... http://www.aft.org/pubs-reports/healthcare/Hart_Report.pdf - 72.7KB/pdf file