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The National Advisory Council on Nurse
Education and Practice (NACNEP) in this
second report to the Secretary of Health
and Human Services and the Congress highlights
its activities during the November 2001-2002
period and presents its concerns and perspectives
on the continuing critical nursing shortage
with particular emphasis on the nurse
faculty shortage. The report was first
required under Section 845 of Title VIII
of the Public Health Service Act when
it was amended by the Nurse Education
and Practice Improvement Act of 1998
(P.L. 105-392).
NACNEP's Activities
During the Year
NACNEP's primary activities during the
year were centered on furthering two aspects
of its prior work: 1) the joint interdisciplinary
activities with the Council on Graduate
Medical Education (COGME) and 2) the issues
underlying the nursing shortage with particular
attention to the nurse faculty shortage.
NACNEP furthered its work on promoting
interdisciplinary activities among the
health professions by participating, along
with COGME, in the organization and coordination
of a multidisciplinary invitational summit
of leaders to discuss and develop strategies
for restructuring health professions education
to advance and better prepare health professionals
to practice in today's health care system.
The summit was sponsored by the Institute
of Medicine with supporting contributions
from a number of Federal agencies and
private health foundations. Over 200 action
steps were generated by the more than
150 invited participants in the summit.
NACNEP and COGME joint recommendations
from their earlier work on interdisciplinary
activities to enhance patient safety led
the Health Resources and Services Administration
(HRSA) nursing and medicine divisions
to enter into five cooperative agreements.
In one agreement, the grantee is developing
nurse and physician faculty leaders in
interdisciplinary education specifically
directed toward enhancing patient safety
who will then lead other nursing and medical
faculty using techniques learned under
this program. In the other four agreements,
the awardees are working on aspects of
improving patient safety at the direct
care level in hospitals and in communities.
All five projects are completing their
first year of the 3-year period for the
agreements.
Given the sustained crisis of nursing
shortages, the status of the nurse workforce
was once again the main focus of NACNEP's
activities during the year. Major segments
of the three meetings NACNEP held during
the year were devoted to the study of
issues underlying the ability to ensure
an adequate nurse workforce to provide
for the health care requirements of the
country. The report especially examines
approaches to alleviate the severe shortages
that have heavy impact on the ability
to provide quality health care to the
nation's population. NACNEP recognized
that steps to address the current nursing
shortages are different than those required
to ensure that the shortages of today
are not also in the picture of the future.
Therefore, the nursing shortage issues
are discussed from two perspectives, the
present and the future.
Current Nursing Shortages
Any actions that could be taken to alleviate
the immediate shortfall in the RN supply
are those pertaining to recruiting and
retaining current RNs in the active workforce
and enhancing the effective use of these
RNs. An examination of the overall numbers
of those who are already educated and
licensed to practice as RNs showed that
a very substantial proportion of the 2.7
million in 2000, 81.7 percent, were actively
engaged in the extensive array of nursing
positions available in the health care
arena. However, nearly 500,000 RNs were
not working in nursing. Among these, 28
percent were employed in non-nursing positions.
Nearly one-half of the RNs who were working
in other occupations cited better hours
as the reason they were not working in
a nursing position. About half of these
pointed to better pay and more rewarding
work in their non-nursing position. Changes
in the nursing workplace, including more
flexible hours, better salaries, and an
environment where work is valued and rewarding,
were cited as possible factors in recruiting
some of these RNs back into nursing.
The vast majority of the RNs who were
not employed in nursing were not working.
The majority of these inactive RNs were
over 50 years old. Younger inactive RNs
were more than twice as likely to have
very young children at home than the RNs
of similar age who were working in nursing
positions. Enhancements such as the provision
for childcare and flexible hours may help
to entice some of these younger inactive
RNs back into the nursing workplace or
shorten the time they are away if they
have temporarily withdrawn from nursing.
Added data on reasons why younger RNs
are not working in nursing might be of
further assistance in determining changes
needed to encourage younger inactive RNs
to return.
While recruitment of RNs for vacant
nursing positions is important it is equally
essential to retain the RNs already on
staff. Several factors that impact on
the ability to retain RNs in the hospital
workforce were examined.
It was pointed out that retention is
a complex issue requiring attention to
both organizational and individual factors,
including both economic and noneconomic
issues. The issue of wages is of particular
concern. The average real annual salary
of RNs showed little change over recent
years, only $200 between 1992 and 2000
according to the National Sample Survey
of Registered Nurses (NSSRN). A recent
study showed that substantial proportions
of RNs believe improved wages and benefits
would help a great deal in solving the
nursing shortage and influence decisions
to remain in the nurse workforce.
Among the many noneconomic factors contributing
to retention, two of the most important
are staffing and scheduling and the presence
of a professional practice environment.
The professional practice environment
is characterized by a well educated nursing
leadership, participatory decision making
in matters related to patient care and
practice, and respectful collegial relationships
with physicians, administrators and other
members of the interdisciplinary team.
However, the body of published evidence
about retention strategies primarily consists
of plans within individual hospitals.
A sustained and concerted effort to develop,
test and report successful retention models
for future decision-making is needed.
The Future
The current shortfall in the numbers
of RNs available to provide health care
services is a precursor to anticipated
future shortages of even greater magnitude.
The nursing population is aging and it
is expected that considerable numbers
will be retiring in the not too distant
future. Nursing schools have suffered
declining enrollments in recent years
and, although the most recent data show
some increase, it is not anticipated that
there will be substantial increases in
nursing school enrollments under current
conditions. At the same time, the aging
United States population and the technological
and therapeutic advances in health care
foretell increasing needs for health care
providers. A recent analysis by HRSA of
the projected supply of and demand for
RNs documents the escalation in the gap
between the demand for RNs and the available
supply. It anticipates that, given current
trends, the demand for RNs would be 29
percent greater than the available supply
by 2020.
Any substantive increase in the number
of working RNs for the future must, of
necessity, come from significantly increasing
the number of individuals who are being
prepared to become RNs. To do so requires
expanding educational resources. An essential
component of such an expansion is the
availability of sufficient faculty. NACNEP,
therefore, considered that a critical
first step in obtaining an adequate future
supply of RNs is to make certain that
a cadre of qualified faculty will be available
to teach them.
Nurse Faculty Shortages
Nursing school administrators throughout
the country point to vacant faculty positions
and difficulties in recruiting. Even within
the current climate of reduced numbers
of applications for schools of nursing,
the lack of faculty has caused a number
of educational programs to limit admissions.
An even greater shortage is anticipated
for the future. The average age of the
teaching faculty in RN educational programs
was 49.8 years in 2000 according to the
NSSRN. It is anticipated that substantial
numbers of current faculty members will
be retiring in the not too distant future.
More than three-quarters of the faculty
were at least 45 years old. The qualifications
to teach in an RN educational program
require a master's degree or a doctorate.
The doctorate is preferred, particularly
in baccalaureate and higher degree educational
programs. The lack of relatively young
faculty members can, in part, be attributed
to the length-of-time involved in an RN
becoming qualified to teach. For example,
according to the NSSRN for 2000, the average
time between the doctoral degree and graduation
from the basic nursing education program
was 20.9 years. The number of graduates
each year from doctoral nursing educational
programs has remained fairly stable despite
a substantial increase in the number of
programs. The scope of positions available
for nurses with doctorates from those
as faculty members has increased dramatically.
So have the types of positions available
for those with master's degrees. Many
of the expanded types of positions available
provide substantially higher salaries
than do those for faculty.
As was the case for the total RN workforce,
once faculty members are recruited it
is equally important to retain them. An
examination of best practices for retention
of faculty members revealed both economic
and noneconomic factors. A system with
annual reviews and established guidelines
for compensation should be established
and opportunities for incentive rewards
should be available. Work environments
should encourage scholarships, mutual
support, interdisciplinary interaction,
and attention to individual professional
needs including opportunities to maintain
clinical expertise and for professional
development. Private funds should be solicited
for endowed chairs or other special faculty
positions, for specialized awards, and
in support of faculty retention plans.
NACNEP also considered the need for
increased diversity among faculty members
to enhance the ability to recruit into
nursing from the rapidly increasing minority
segment of the population. Having a critical
mass of minority faculty has been shown
to be a major factor in the recruitment
and retention of minority students. The
Council also looked at the impact of informatics
both from the aspect of student recruitment
and the need for faculty. On-line courses
could facilitate attracting students from
areas remote from educational facilities.
They may impact requirements for faculty
because of the faculty preparation and
student interaction time needed. But,
on-line learning could provide for collaborative
sharing of resources among schools of
nursing. As both faculty and students
become more proficient in using on-line
learning, acceptable student-faculty ratios
may increase.
Conclusions and Recommendations
NACNEP's review of the current state
of nursing resources in the country and
the necessary steps to assure an adequate
supply was made in acknowledgement of
the changing environmental context, which
includes external threats of terrorism
and an awareness of patient safety and
quality issues. Nurses and nurse faculty
are critical elements in the nation's
ability to address these external issues.
NACNEP divided its recommendations into
two areas: 1) actions to further its work
in providing advice and recommendations
pertaining to the nurse workforce, education
and practice improvement and 2) actions
that would be important in addressing
the nurse faculty shortage, a critical
first step in alleviating a potential
nursing shortage for the future. In completing
its conclusions and recommendations, NACNEP
especially recognized and commended the
passage of the Nurse Reinvestment Act
(P.L. 107-205) in August 2002. NACNEP
noted that major new authorities included
in the Act responded to a number of the
actions suggested in its first report
and issues raised in this second report
that were essential to alleviating the
nursing shortages. The new authorities
added to the ability of ensuring adequate,
qualified, RN resources in the country
through Title VIII. NACNEP looks toward
sufficient funding for these new initiatives
and the other portions of Title VIII so
that this legislation can effectively
contribute to the alleviation of a crisis
in the nation's delivery of quality health
care to the population.
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