More Nurses Are Needed

·         Registered nursing was among the fastest growing occupations in the 1990s.  This trend continued. Between 1997 and 2008, the number of employed RNs increased from 2,065,000 to 2,778,000 —an increase of 25.7%.[1]

·         In 2008, the U.S. Department of Labor identified “Registered Nurse” as the occupation expected to experience the largest job growth in the 10 years from 2006 to 2016.  The need for RNs is projected to grow rapidly, rising by 23.5% between 2006 and 2016, compared to 10.4% during the same period for all occupations.  More than 500,000 openings for RNs are projected by 2016 due to growth and replacements.[2]

·         The number of Licensed Practical Nurses (LPN) and Licensed Vocational Nurses (LVN) is expected to increase 14% between 2006 and 2016.  The number of LPNs/LVNs is projected to increase during this period from 749,000 to 854,000.[3]

 

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 6.9% in 1995 to 8.3% in 2008, and the percentage of male LPNs/LVNs increased in the same time frame from 4.6% to 6.7%.[4]

·         Most nurses are white, although the percentage of minorities among nurses is increasing.  From 1995–2008:

—  The Black or African American share of RN positions increased from 8.4% to 10%.  The proportion of black LPNs/LVNs also increased from 19.6% to 22.1%.  African Americans made up 11% of the total labor force in 2008.[5]

—  The percentage of Hispanic or Latino RNs increased from 2.6% to 4.7% from 1995–2008.  Latinos’ share of LPN/LVN positions increased from 3.7% to 7.1%, while they made up 14% of the labor force in 2008.[6]

·          The nurse population is aging, since fewer people are entering the profession.  The average age of RNs increased from 36 in 1980 to nearly 47 in 2004.  Only 26.6% of RNs are under 40.  This trend declined steadily from 1980, when 40.5% of RNs were under 35, and in 2000 when 31.7% were under 40.[7]

 

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 projects that the problem will expand to 44 states and the District of Columbia by 2020.[8]  Another study predicts a shortfall of 400,000 RNs by 2020,[9] while yet another projects a shortage of 800,000 by 2020.[10]   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.

·         Nursing School Enrollment:  Enrollments in entry-level RN baccalaureate programs began declining in 1995 and continued until 2000.  Recently, however, there has been resurgence in the number of students studying nursing, with eight consecutive years of increasing enrollments.  2008 saw a 2.2% increase in enrollments, with 5.0, 7.6, 9.6, 14.1, 16.6, 8.1, and 3.7 percent increases in 2007, 2006, 2005, 2004, 2003, 2002, and 2001, respectively.  The number of graduates from entry-level baccalaureate programs also increased by 8.2% from 2007 to 2008.  While this increase represents a positive trend, 49,948 qualified applicants were turned away from baccalaureate and graduate nursing programs in 2008 due to an insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints.[11]

·         Shortage of Faculty for Nursing Schools:  The shortage of faculty makes it impossible to train sufficient nurses, a problem which is intensifying as enrollments at nursing schools increase.  The American Association of Colleges of Nursing (AACN) reported a national nurse faculty vacancy rate of 7.6% in 2008.  A shortage of faculty has been cited as the reason why the 49,948 qualified applicants were denied admission.  Of these, some 3,000 could potentially have filled faculty roles.[12]  The AACN also reports that:

—    Nearly 63% of nursing schools need additional faculty;[13]

—    66.6% of vacant positions are on a tenure track and should be appealing to qualified candidates;[14]

—    Nearly 75% of available positions are at least assistant or associate professorships;[15]

—    While a small percent of vacant positions do not even require classroom time, most (73.1%) require a combination of classroom and clinical time;[16] and

—    Schools claim that shortages exist because of insufficient funding and limited salaries, and a diminishing pool of candidates.[17]

Understaffing Affects Nurses and Patients:  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.

·         The Institute of Medicine (IOM) concluded that the environment in which nurses work is 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.[18]

·         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 unanticipated problems that result in death or injury to hospital patients.[19]

·         A 2006 study by Heather K. Spence Laschinger, R.N., Ph.D. and Michael P. Leiter, Ph.D., found that patient safety outcomes are related to the quality of the nursing practice work environment.  Strong correlations exist between low staffing levels and increased emotional exhaustion, which leads to more patient complaints, nosocomial infections (infections received from hospital care, such as urinary tract or staph infections) and medication errors.[20]

·         Massachusetts nurses revealed that 87% of nurses had too many patients for which to care, resulting in dire consequences:  nearly one in three nurses (29%) report patient deaths directly attributable to having too many patients; 67% report an increase in medication errors due to understaffing; 64% report an increase in complications due to understaffing; 54% report readmission of patients due to understaffing; 52% report injury and harm to patients due to understaffing; 1 in 2 nurses report that poor staffing leads to longer stays for patients, which cost more; and only 4% of RNs report that patient care in their hospitals is excellent.

Of the 600 nurses polled:  93% report being burned out by excessive patient loads; 65% agree that working conditions in hospitals are “brutal” for nurses; 75% report that their managers schedule too few nurses for their shifts; 70% report being “floated” to assignments in other areas of the hospital for which they lack proper orientation or training; 60% report that hospital administrators assign mandatory overtime instead of staffing properly; 58% report that hospital managers assign nursing duties to non-nurses instead of hiring RNs.  Eighty-six percent support legislation to regulate RN-to-patient ratios in hospitals.[21]

Nurse -to-Patient Ratios:  With managed care restructuring the health care industry in the 1990s, hospitals reduced staffing levels to lower costs.  Nurses now 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 LPNs/LVNs added to RNs’ patient load.[22]   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.[23]  The IOM study  recommended that nurse staffing levels be raised in all health care facilities.[24]

·         Implementing laws regulating nurse-to-patient ratios can have a big effect on understaffing.  California passed a landmark RN staffing ratio law in 1999 (implemented in 2004).  Vacancies for registered nurses at local (Sacramento) hospitals have plummeted 69% since early 2004, according to the January 11, 2008 Sacramento Business Journal.  The California Board of Registered Nursing reports that after the enactment of this law, the number of actively licensed RNs in California increased by nearly 10,000 a year, compared to just 3,200 a year previously.  This number is almost seven times more than the total state health officials said would be needed to meet ratios for general medical/surgical units.  There has been a 60% increase in RN applications.[25]

·         Striking RNs at Mt. Clemens General Hospital in Mt.Clemens, Michigan, reached a new contract where a three percent pay raise offered by the hospital was turned down in favor of a two percent raise and the hiring of 25 additional nurses in order to offer better, more professional patient care.[26]

 

·         Nurse members of the Michigan Nurses Association/United American Nurses, AFL-CIO, at Borgess Medical Center in Kalamazoo, Michigan, found that in the two years since a management-instituted increase in the RN-patient ratio, patient satisfaction with their care dropped from 94.45 percent to 77.03 percent. Additionally, patient falls and hospital-acquired pressure ulcers increased significantly, while staff satisfaction and retention have decreased.[27]

 

  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.  Even ‘voluntary’ overtime can be mandatory.  Nurses are sometimes told to determine among themselves who will ‘volunteer’ for overtime before any of them are allowed to go home.  As a result over 60% of RN’s report being “forced to work voluntary overtime.”[28]

·         Fourteen states (CA, CT, IL, MD, MN, MO, NH, NJ, NY, OR, RI, TX, WA, WV) have enacted laws or regulations on mandatory overtime for nurses, most prohibiting hospitals from requiring overtime except in the event of a public health emergency.  Mandatory overtime legislation or regulation has been considered in another eight (AZ, FL, ME, NE, OH, VT, WA (to extend existing protections to the public sector), WI).  On the federal level, the “Nurse Staffing Standards for Patient Safety and Quality Care Act of 2007” (H.R. 2123) introduced by Representative Jan Schakowsky (D-IL) would restrict mandatory RN overtime to times of emergency and establish minimum nurse: patient ratios.[29]

·          Burnout:  High rates of emotional exhaustion and job dissatisfaction are strongly associated with inadequate staffing and low nurse-to-patient ratios.

·         A 2007 study in the American Journal of Nursing found that among new RNs:  64% work overtime regularly; 66% work 12-hour shifts; and 32% say that three or more days a week they have more work than can be done.  37.2% of RNs who leave their first job cite stressful working conditions as the reason.[30]

·         The Aiken study found each additional patient over four per nurse corresponds to a 23% increased risk of burnout, and a 15% increase in the risk of job dissatisfaction.[31]

·         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 linked to the departure of RNs from the nursing work force.  A survey conducted by the American Nurses Association (ANA), found 33% of nurses under the age of 30 intended to leave their job within the year.[32]

·         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.[33]

·         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.[34]  The proportion of RNs who work in hospitals fell from 66.5% in 1992 to 59% in 2000.[35]  There are currently 500,000 RNs in the U.S. who are not practicing their profession—fully one-fifth of the current RN workforce and enough to fill current vacancies twice over.[36]

 

 Healthcare Employers Increasingly Recruit Nurses from Overseas:  This allows them to avoid making fundamental changes to improve the quality of care, retain nurses, and make nursing an attractive career.  Currently one-third of new RNs in the U.S. are foreign born.[37]

·         In 2005, Congress allocated 50,000 visas for RNs, an amount that was filled by November 2006.  Lobbyists continue to work for more specially allocated visas for nurses and to entirely eliminate any numerical restrictions on RN visas.[38]

·         There are at least 267 U.S.-based international nurse recruitment firms operating in 74 countries.  This represents a significant increase from the 30-40 such companies that existed in the late ’90s.  While some companies try to avoid recruiting from developing nations, at least 40 firms have been found to recruit from Africa, Latin American and the Caribbean, all regions facing serious nursing shortages.[39]

·         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.[40]

·         Vacancy rates for nurse positions in Jamaica and Trinidad are 59% and 53%, respectively, due to nurse migration and the high demand for English speaking nurses.  Even the Philippines, a country that has embraced a “nurse for export” industry in the past and has historically provided a majority of U.S. foreign nurses, can no longer keep up with the demand.  More nurses are leaving the Philippines than are being trained and public hospitals are reporting nurse-to-patient ratios as bad as 1:60.  The Philippine Hospital Association claims that 200 hospitals have closed due to a shortage of doctors as the nation’s physicians retrain as nurses and emigrate to the U.S.[41]

In addition, extensive use of temporary visa programs frequently depresses wages and guest workers themselves are particularly open to exploitation.

 

 Nursing Is a Dangerous Occupation

With 131.6 nonfatal injuries per 10,000 full-time workers nurses are at a higher than average risk of injury or illness due to occupational hazards.[42]

·         Registered nursing is one of 10 jobs with the highest levels of occupational injury or illness requiring days away from work.  Nursing aides, orderlies, and attendants reported 52,150 cases in 2005.  The median number of days away from work was five.  The occupational category of health care and social assistance accounted for 94% of the reported injuries and illnesses.  There were nearly four times the number of injuries and illnesses to women than to men.[43]

·         In a 2001 survey, the American Nurses Association found that 40% of their members had been injured in the previous year, including needle sticks, but many had not reported the injuries.[44]

·         Hospitals and nursing care facilities ranked number one and two in number of nonfatal occupational injuries by industry in 2005.[45]

·         Overworking results in injury:  39% of RN injuries resulting in missing work were attributed to over exertion in general.[46]

·         Nurses are exposed to unconventional danger:  5% of RN injuries were attributed to assaults on the job.[47]

·         RNs have the fifth highest incident of musculoskeletal disorders (MSD) among all occupations with 59.1 cases for every 10,000 RNs.[48]

 

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.

·         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.[49]  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.

·         Adjusted for inflation, RNs’ median weekly earnings increased by only 4.5% from 2000 to 2008.[50]

·         Between 2000 and 2008, RNs’ wages increased by 4.5%, during which time labor force earnings as a whole increased by 0.3%.  This translates to real weekly earnings of $976.49 in 2000 to $1022 in 2008.[51]

·         LPNs’/LVNs’ median weekly earnings increased by 7% from 1996 to 2006.  In the past eight years, these earnings increases have accelerated, increasing 7% from 2000–2008, showing consistent growth for the decade.  In dollar amounts, median real weekly earnings for LPNs/LVNs increased from $641.41 in 2000 to $692 in 2008.[52]

·         Unions can significantly affect nurse wages.  Nurses covered by a union contract in 2008 earned 16.5% more per week than non-covered nurses, while LPNs/LVNs represented by unions earned a wage premium of 21%.  This translates to a weekly earnings increase of about $206 for RNs and $173 for LPNs/LVNs—an annual gain of about $10,300 and $8,650, respectively.[53]

·         In cities with a strong union presence, wages are higher even for nurses who are not in unions.[54]

 

 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%.[55]  The healthcare percentage is a significant increase from 2000, however, when only 1.5% of payroll for health care 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.[56]

·         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, including health insurance, retirement, medical care, dental care, disability coverage, paid vacation and holidays.[57]

 

 After Accelerating for a Decade, Union Organizing Declines

·         Health care workers represent a large portion of all workers holding representation elections.  More than one in eight of the 2,674 NLRB representation elections held in 2006 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:  58.8% for health care, compared to 55.5% for all industries in 2006.[58]

·         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.  Between 2000 and 2006, the number of representation elections for nurses decreased by almost 38%, compared to a drop of 36% for all industries.[59]

·         Among RNs, union membership dropped off between 1994 and 1995, falling from 17.3% to 15.2%.  In the decade since, union membership has rebounded slightly, to 19.8% in 2008.  Union density fell from 12.8% in 1995 to 9.4% in 2008 among LPNs/LVNs.[60]

·         The percentage of RNs represented by a union also jumped downward between 1994 and 1995, from 20.1% to 17.6%.  Again, in the following decade there was a rebound, to 21.5% in 2008.  For LPNs/LVNs, union representation dropped from 15.6% to 9.7% in 2008.[61]

Recent National Labor Relations Board (NLRB) Decisions Hinder Nurses’ Rights

·         Supervisors lose their rights to collectively bargain, complain or protest working conditions without risk of being fired and a supervisor could lose their job for refusing to help an employer fight a labor union.[62]

·         In September 2006, the NLRB ruled to expand the definition of “supervisor,” and allow employers to take union protections away from nurses and other workers.  In a set of cases known as Kentucky River, the NLRB ruled that permanent or rotating charge nurses should be considered supervisors.  Dissenting members of the NLRB panel wrote that the decision “threatens to create a new class of workers under federal labor law:  workers who have neither the genuine prerogatives of management, nor the statutory rights of ordinary employees.” 

·         In Oakwood Healthcare Inc. the NLRB found that 12 charge nurses were supervisors under the law because of their authority to assign nurses to particular patients.[63]

·         The Kentucky River cases could cause 8-34 million skilled workers across the country to be designated as supervisors.[64]

·         843,000 RNs and 123,800 LPNs/LVNs will be affected by the Kentucky River decisions.[65]

·         Under Oakwood, 64 out of 153 nurses at the Salt Lake Regional Medical Center were declared supervisors.  For some departments this meant 10 out of 12 nurses or ratios of 12 supervisors for every five employees.[66]

·         Unions, DPE, and the AFL-CIO are presently at work to fight the Kentucky River ruling and its consequences, including recruiting co-sponsors for the RESPECT ACT (H.R. 1644/S. 969), which seeks a return to the intent of Congress in defining who is a “supervisor” under the National Labor Relations Act.[67]