The Decreasing Supply of Registered Nurses: Title and subTitle BreakInevitable Future or Call to Action?

The future of health care in the United States increasingly pivots on a sufficient supply of appropriately educated and skilled professional registered nurses (RNs). The study by Buerhaus and colleagues¹ in this issue of THE JOURNAL should create concern among physicians and RNs as well as others charged with providing, managing, or financing health care services. Buerhaus et al forecast that the future sufficient availability of RNs is not ensured given the continued aging of the RN workforce and the decreased propensity for potential students to choose nursing careers. The most important factors contributing to the aging of the nursing workforce are a long-term trend of declining interest in nursing by women, who today enjoy a wide choice of career opportunities, and the decrease in the number of individuals born after 1955 who have pursued nursing as a career.¹

The analysis by Buerhaus et al comes on the heels of a recent report by the American Association of Colleges of Nursing, which found that enrollments in entry-level baccalaureate nursing programs decreased by 4.6% in fall 1999—the fifth consecutive decline in as many years.² In addition, recent data from the National League for Nursing (NLN) indicate declines in enrollments in all types of entry-level nursing programs (Theresa M. Valiga, RN, EdD, NLN, May 30, 2000, unpublished data for 1998).

Attracting a cadre of young, college-bound students will require reform in nursing education and in the licensure and certification mechanisms used to grant practice to RNs with different educational preparation. Currently, entry-level nursing education is offered in 3-year hospital diploma programs, 2-year associate-degree programs (ADs) in community colleges, and 4-year university-based baccalaureate programs (BSN). Graduates of the 3 types of programs receive the same license to practice and most often are employed in the same entry-level positions.

Hospital-owned diploma programs were based on an apprenticeship model of training but have evolved to include some college course work in the social and physical sciences. Although more than 1100 diploma programs existed in the first decade of the 1900s,³ the number of diploma programs (currently 89⁴ ) and the percentage of entry-level graduates from these programs (currently, 4% [NLN data for 1998]) have declined rapidly as educators, employers, and others recognize the need for educational changes in nursing.

Associate-degree nurse education programs were established in the late 1950s in response to a nursing workforce shortage and as "an experiment in technical education" for nurses.⁵ These AD programs provide students with limited general studies and physical sciences course work and include nursing courses directed at the care of patients with common, well-defined diagnoses. The preponderance of AD programs, which totaled 876 nationwide in 1997⁶ and now account for 59% of new entry-level graduates (NLN data for 1998), may have contributed to the aging of the RN workforce. In 1996, graduates of AD programs were, on average, aged 33.5 years vs 28.0 years for graduates of basic baccalaureate programs.⁷

Baccalaureate nursing programs are offered in 661 four-year colleges and universities and include a base of liberal arts education and core physical and social sciences course work as well as the nursing science curriculum.² Baccalaureate graduates represent 37% of all new entry-level RNs (NLN data for 1998).

The current RN workforce includes 27% with diplomas, 32% with ADs, 31% with BSNs, and 10% with master's or PhD degrees.⁷ Although about one third of all students enrolled in BSN programs are AD- or diploma-prepared RNs acquiring the BSN,² these students represent less than 3% of all RNs without the BSN.⁷ Only 16% of RNs prepared initially at the AD level acquire a BSN or higher degree in nursing.⁷

The continuation of a system of nursing education that provides graduates of 3 different levels of nursing programs with the same license and role expectations creates a major disincentive to attracting an adequate supply of BSN-educated RNs for the future. For instance, in focus groups conducted to gather information and perceptions from nurse educators regarding factors associated with declining BSN enrollments, nurse educators consistently reported that potential BSN students were discouraged from pursuing a nursing career by the confusing array of entry-level options available in the profession and noted that such confusion had led many secondary school students and guidance counselors to not view nursing as an intellectual endeavor.⁸

At the same time that BSN enrollments are declining, an increasing amount of evidence has demonstrated an association between health care quality and the educational level of nursing staff, the number of RNs in the clinical setting, and the perceived value placed on nursing by the practice setting.^{9 - 16} These findings have been documented in institutions designated as "magnet" hospitals by the American Nurses Credentialing Center. This center, a major national certification organization, established the magnet hospital program as a mechanism for recognizing excellence in nursing care. Hospitals seeking this designation must meet 14 standards through a process that entails both written documentation of the institution's ability to meet the standards and an on-site evaluation review.

The original series of magnet hospitals were selected in the 1980s and recognized for their ability to attract and retain RNs in a time of shortage.⁹ Magnet hospitals have a higher proportion of nursing staff prepared at the BSN level (average, 59% vs 34% for all hospitals).^{9 ,12 ,17} Despite the common perception that RNs with a BSN or more advanced degree leave the direct patient care setting, 64% of all BSN-prepared RNs are employed in hospitals in direct patient care (64% of RNs with ADs and 47% of RNs with master's degrees are employed in hospitals).⁷

Aiken et al^{12 ,14 - 16 ,18} found higher levels of BSN-educated nursing staff, nurse-to-patient ratios, and nurse satisfaction in magnet hospitals. In a 1994 study, Aiken et al¹⁸ investigated whether 1988 mortality rates for Medicare patients differed significantly between 39 institutions designated as magnet hospitals and 195 matched control facilities that did not hold that designation. After controlling for a number of factors known to influence mortality, such as number of beds, average daily census, organizational structure, facilities and services, medical staff characteristics, Medicare discharges, annual budget, and RN-staff mix, the researchers found that Medicare patients in magnet hospitals had significantly lower mortality rates (approximately 5% less excess mortality) than matched control hospitals. Aiken et al suggested that "the mortality effect derives from the greater status, autonomy, and control afforded nurses in the magnet hospitals, and the resulting impact on nurses' behaviors on behalf of patients."¹⁸

Using similar statistical matching and comparison techniques, Aiken et al¹⁴ reported that patients with acquired immunodeficiency syndrome in magnet hospitals had significantly higher satisfaction levels and a nonsignificant trend toward lower mortality rates.¹⁵ Moreover, RNs in magnet hospitals had significantly lower burnout rates and a nonsignificant trend toward lower needlestick injury rates.¹⁶

In 1998, the US Congress charged the Division of Nursing, US Department of Health and Human Services, with implementing strategies to enhance the production of BSN-educated RNs.¹⁹ In the same year, citing the complex needs of veterans, the Department of Veterans Affairs announced its intention to require the agency's RNs to have a BSN by 2005 to achieve a position above the first entry-level pay-grade positions. The Department of Veterans Affairs has initiated an extensive program of educational support to assist its nursing staff to acquire additional education in an effort to facilitate improvement of the staff's competencies and knowledge base.²⁰

Studies documenting hiring preferences and salary differentials provided for RNs with different levels of nursing education are limited. In a 1987 American Hospital Association survey, nurse executives in community hospitals reported that they would prefer to have, at minimum, an average of 55% of their nursing staff prepared with a BSN.²¹ In a 1999 survey of University Healthsystem Consortium chief nurse officers, respondents reported their preference for an average of 70% of their staff RNs to be prepared at the BSN level.²² Although 72% of these nurse executives indicated that they perceived that BSN-prepared nurses are better equipped than RNs with AD or diploma education to apply critical thinking and analysis, use evidence-based practice, provide leadership, and focus on prevention and patient education, only 44% of their institutions provided differentiated salaries, and only 33% applied differentiated role descriptions based on education.²²

Decisions regarding skill mix, differentiated roles or salaries, and the appropriate regulatory mechanisms to validate knowledge and competencies should be based on a clear analysis of the health care system's requirements for nursing care. The development of a rationalized model for credentialing RNs also should be based on the different educational preparation and competencies achieved in AD or BSN programs. This could be implemented through the development of different licensure examinations for graduates of different levels of educational preparation. An alternative would be to follow the model used by physicians to develop a certification process that validates the different competencies acquired by specialty training.

This discussion is reminiscent of the concerns that confronted the medical community in the early part of the 20th century when medical specialty training was available through a wide array of both commercial and university-based training programs. As noted by Ludmerer,²³ a consensus developed in the medical community regarding the need to develop uniform expectations for the scholarly and clinical training activities necessary to ensure the quality of medical specialists. This consensus was accompanied by a framework of credentialing mechanisms (ie, specialty board examinations) to validate the different training experiences of specialty clinicians and the practice authorities that should be given to them. A similar consensus must be developed for nursing and accompanied by a more thorough and scholarly assessment of the skill mix requirements of the types of RNs needed to deliver the best care to patients amid the ever-increasing complexities of the current health care system.

Similar to medical specialty certification, master's degree–educated advanced-practice RNs, who include nurse practitioners, nurse midwives, clinical nurse specialists and nurse anesthetists also hold certification in various specialties, often as a mechanism for acquiring practice authority. In addition, entry-level RNs with extensive experience in specialty areas such as critical care or oncology are eligible to take specialty certification examinations that validate this experience.

In its 1996 report on nurse staffing in hospitals and nursing homes, the Institute of Medicine recommended a comprehensive study of the relationship between skill mix and quality of care.²⁴ Data from this type of analysis will provide the framework and rationale for differentiated credentialing mechanisms, whether by licensure or professional certification processes.

Several groups have begun to address these concerns. In a recent joint report, the American Association of Colleges of Nursing, National Organization for Associate Degree Nursing, and American Organization of Nurse Executives determined that real differences exist between AD and BSN educational experiences and the competencies achieved in these programs.²⁵ The American Nurses Credentialing Center intends to implement a certification process for nurses with the BSN degree to validate the role competencies achieved in BSN programs.²⁶ Work to date on this Certified Professional Nurse examination has included a national role delineation study to identify competencies held by BSN-prepared nurses only.²⁷ This examination may provide an appropriate means of validating BSN competencies.

These efforts to validate educational competencies also should be accompanied by restructuring practice environments that employ nursing staff according to differing RN educational and patient care capabilities. In particular, these environments should allow for the full utilization of the professional-level competencies of BSN graduates. Studies of magnet hospitals have found that a well-regarded nursing staff headed by a chief nurse executive with authority to lead and manage that staff is associated with positive outcomes such as ensuring patient satisfaction, decreasing mortality rates, and retention of a stable workforce.^{9 ,12} The higher RN staffing level in these hospitals is evidence of their ability to recruit and retain high-quality RNs to remain in patient care. Similarly, a recent study of community and academic acute-care hospitals indicated that the most successful approaches for recruiting and retaining RNs over the long term included models that allow RNs more predictable and flexible work schedules, autonomy over their own practice, and shared governance programs in which RNs actively participate in decision making about patient care issues.²⁸

The stability of the complex systems of health care in the United States depends on an available supply of well-educated nursing personnel with clearly defined roles that are sanctioned through a system of licensure and certification. Reforming the education and credentialing mechanisms for nursing, restructuring work environments, and developing systems of care that empower RNs to use their professional skills are essential. Recognizing the contributions of RNs to the delivery of high-quality health care and to the well-being of those health systems will provide potential nursing students with a career option that is attractive and rewarding. Without dramatic reform, the shortage of skilled professional RNs predicted by Buerhaus and colleagues is inevitable.