May 2001 (Vol. 1, No. 7)
Will Wisconsin Have a Nursing Workforce to Meet Future Health Care Needs?
By Patricia Lasky, Associate Dean, University of Wisconsin School of Nursing, Madeline Wake, Dean of Marquette School of Nursing and Catherine Frey

A national study, published in the Journal of the American Medical Association in June 2000 by Peter Buerhaus Ph.D., R.N., found a dramatic aging of the registered nurse population along with a lack of nursing students in the pipeline to replace retiring nurses. The study attributes the aging work force to recent expansion of career opportunities for women and the growth of 2-year associate's degree nursing programs, which typically attract older students. The study also predicts that over the next decade, aging of RNs will persist and that by 2020 there will be a 20% shortage in the number of projected RNs required. The Buerhaus study suggests that the aging of the RN workforce will result in the need for fundamental restructuring changes for employers, especially hospitals who employ nearly 60 percent of all working RNs nationally.

The findings of the Buerhaus study, and more recently the 2000 National Sample Survey of Registered Nurses, suggest that the current nursing shortage, unlike past shortages, is more complex due to multiple demographic and social changes in society. The demand for skilled nursing services has changed significantly over the past decade. Technology, escalating levels of acuity and chronic disease, both in hospital and the community practice settings, are some of the factors influencing demand. An equally powerful demographic force is the increasing ethnic diversity of the population - but perhaps the single most important factor is an aging population. This Issue Brief will discuss Wisconsin's nursing workforce trends and solutions to address nursing shortages over the next decade.

Nursing Workforce Trends

Preliminary findings from the Health Resources and Services Administration’s (HRSA) 2000 National Sample Survey of Registered Nurses released in March 2001, found that the rate of individuals in Wisconsin entering the profession between 1996 and 2000 has not slowed as it has nationally. Wisconsin had 5,618 more registered nurses in 2000 than in 1996, or an increase of 10.6%, compared to 5.4% nationally. The HRSA Survey also tracks the number of RNs per 100,000 population as a measure of workforce adequacy. Across the US, there is a large variation in the number of employed RN's per 100,000 population. The figures range from 520 in Nevada to 1675 in D.C. Wisconsin, at 893, is similar to other states in the East North Central Region of the US, but higher than the national average of 782.

However, compared to the nation, the increase in Wisconsin RN's has not translated into more employed Wisconsin nurses, since many are choosing not to be employed in nursing jobs.The state has seen major shifts in area of employment as more nurses are also choosing work outside of traditional nursing roles. These changes are likely to increase the employment stresses on nurses who do continue to work in traditional nursing settings, such as hospitals. According to the HRSA survey, the percent change in Wisconsin RNs not employed in nursing over the past four years increased by 37%. This compares to an 11.7% change in the US and a 15% change in the East North Central Region. See Table 1.

Employment

Over the past decade, economic pressures within health care settings have led to efforts that have reduced hospital length of stays, resulting in a higher level of patient illness and more activity in hospital and home care settings. The change in the work environment has led to more stress and consequently less satisfaction on the part of staff nurses. The high-pressure environment along with declining resources has made the overall work environment less attractive, particularly for older nurses.

Table 1. Registered Nurse Population from 1996 to 2000

 

Nursing Population 1996 2000 Percent Change
# RN's in United States 2,558,874 2,696,540 5.4%
# RN's in Wisconsin 53,040 58,658 10.6%
Employed RN's per 100,000 pop (US) 798 782 -2%
Employed RN's per 100,000 pop (WI) 876 893 2%
# RN's Employed in Nursing (US) 2,115,815 2,201,813 4.1%
# RN's Employed in Nursing (WI) 45,202 47,895 5.6%
# RN's not Employed in Nursing (US) 443,059 494,727 11.7%
# RN's not Employed in Nursing (WI) 7,838 10,763 37.3%

According to the HRSA Survey, fewer Wisconsin RN's work full time than the national average; Wisconsin at 60.8% compared to the national average of 71.6%. However, more Wisconsin nurses are working full time in 2000 than there were in 1996. In 2000, while 60.8% of Wisconsin RNs in the workforce worked full time in nursing, 39.2% reported working on a part time basis. In comparison, in 1996 an estimated 58.4% worked full time and 41.6% worked part time.

Over the next decade, Wisconsin's population is expected to grow slower and older than the nation. As the aging population will require more care, this will result in even greater demands on nurses in traditional health care settings. According to the Wisconsin Department of Workforce Development, 13.3% of Wisconsin's population in 1995 was elderly. By 2005, the proportion is expected to increase to 20.4%.

Education

The percentage of Wisconsin nurses with education at baccalaureate or higher levels (50%) is higher than the national percentage (42.9%). However, a higher percentage is desirable. The National Advisory Council on Nursing Education and Practice has recommended that by 2010 at least two-thirds of all registered nurses hold baccalaureate or higher degrees. With the increased complexity of nursing work, similar trends in nursing educational requirements are seen internationally. Australia, Canada (effective 2005), Colombia, and Portugal have enacted legislation requiring baccalaureate preparation for entry into professional nursing practice. The need for higher education level further complicates the nursing demand.

During the past four years there has been a shift in graduations from basic nursing education programs away from diploma programs to either associate degree or baccalaureate programs. According to the 1996 HRSA survey, in Wisconsin, 23.1% of RNs in the workforce reported their highest level of education as a nursing diploma, 28.1% as associates degree, 39.4% as a baccalaureate degree, and 9.5% as master's or doctorate degree. By comparison, in 2000 the proportion of the Wisconsin nursing workforce was 16.1% as diploma, 33.6% as associates degree, 41.3% as a baccalaureate degree, and 8.8% as master's or doctorate degree. This shift has been very similar to national trends.

Solutions

Nursing workforce is a complex national concern, made more critical by Wisconsin demographic projections. Actions must be taken to assure that the health and nursing needs of Wisconsin residents are met in the future. It is unrealistic to think that the demand for number of nurses will be met without some health system redesign. The major national nursing organizations agree that the nation will not have the numbers of nurses to meet future demands unless the system is changed. The private sector may be called upon to support creation of new care delivery models meeting the needs of Wisconsin residents for the near future. The nursing shortage may be summed up in a quote from Janet Coffman, Associate Director of Workforce Policy at the UCSF Center for Health Professions; "The fairly recent expansion in opportunity for women means that the profession can no longer count on a large number of young women being induced to enter the fields for lack of other options. This means that nursing will have to re-position itself as an attractive professional career to compete successfully for the interest of those entering the work force".

In order to have an adequate nursing workforce for Wisconsin, multiple strategies are necessary. Three first steps are recommended to address Wisconsin’s nursing workforce needs. First, the lack of statewide data about nursing workforce is a problem that often receives little attention and one of the foremost challenges in health care policy and planning today. The timing is critical to begin to improve data collection and knowledge to enhance systems of care needed now and in the future. California, Texas and Maryland have conducted in-depth studies of nursing workforce resulting in clear, state-specific plans. Wisconsin needs better quality data on nursing workforce and a comprehensive plan. Second, the adjacent states of Minnesota and Illinois have nursing education loans, which are forgiven after graduation with periods of in-state employment. Such legislation would encourage educated nurses to stay in state. Third, national nursing organizations and other leadership groups are calling for system re-design. Nursing work redesign should join efforts of education and practice to differentiate nursing roles based upon education with differentiated licensure. This would mean changes in education and practice for technical and professional nurses. In addition, focused engineering efforts on work redesign using technology, especially communications technology, would also improve the work environment of nurses. Public and private funding could support Wisconsin efforts in such work redesign.

References:

The Registered Nurse Population, National Sample Survey of Registered Nurses, March 2000, Preliminary Findings, HRSA, BHP, Division of Nursing, February 2001

Peter Buerhaus Ph.D., RN, Douglas, Staiger Ph.D., David Auerbach MS, "Implications of an Aging Registered Nurse Workforce" JAMA, June 14, 2000

Coffman J, Spetz J, Seago JA, Rosenoff E., O'Neil E., Nursing in California: A Workforce Crisis, San Francisco, CA: California Workforce Initiative and the UCSF Center for the Health Professions, January 2001