T he robert wood johnson Foundation (RWJF) is dedicated to improving the health and health care of all Americans. Central to this mission is transforming the way care is delivered at the bedside to reduce the shortage in nurse staffing and improve the quality of nursing care. 1 Nurses are the linchpins in providing high-quality patient care in hospitals. To attract high-quality staff, enable them to do their best work, and keep them as long-term employees, improvements must be made in the organization of work and use of information technology (IT); physical design and allocation of space; and hospital leadership and culture. Working with various partners, the RWJF expects to build support for a new kind of hospital that reflects the needs and realities of the twenty-first century: a hospital where patient safety is assured, quality of care is paramount, efficiencies are maximized, and staff are satisfied with and actively supported in their jobs. Although this initiative begins with the nursing profession, the results from these efforts are expected to affect all health care workers in hospitals and the millions of patients whom they serve. Throughout the past few decades, U.S. hospitals have faced cyclical shortages of nurses; in 2000 an estimated 126,000 hospital nursing positions were unfilled. 2 The percentage of nurses working in hospitals dropped from 59 percent in 2000 to a little more than 56 percent in 2004. 3 The current nurse shortage is driven by a broad set of factors related to recruitment and retention—among them, fewer workers, an aging workforce, and unsatisfying work environments—that have contributed to a different kind of shortage that is more complex, more serious, and expected to last longer than previous shortages. Too few new nurses are being trained (largely because of a shortage of nursing school faculty), but to a greater extent, the current shortage results from the reluctance of newly educated nurses to make their careers in hospitals. Nurses cite stress-related burnout and the large amount of time they must spend on nonnursing tasks as top reasons for feeling dissatisfied with their jobs; 43 percent of nurses report that they plan to leave their jobs within three years. 4 Thus, the average age of hospital nurses is in the mid-forties. 5 On average, nurses work eight and a half weeks of overtime every year. 6 Recent studies continue to show that taking care of too many patients and working overtime and long shifts—twelve- and sixteen-hour shifts are not uncommon—are associated with errors and poorer quality of care. 7 A kind of vicious circle surrounds the nursing profession. Fewer people are working in nursing, which has led to a shortage. Because of the shortage, nurses who remain in hospital work must care for more patients under increasingly difficult working conditions. Because of these strained working conditions, more nurses leave the hospital workforce, thereby worsening the shortage and making recruitment of new nurses more difficult. The nurse shortage also has important cost implications for hospitals. 8 Although estimates vary widely, the cost of recruiting and training one new nurse for a medical-surgical floor is usually equal to 100 percent of a nurse’s annual salary—$42,000–$60,000; that investment is much higher for an intensive care or emergency department (ED) nurse. 9 Although there has been an increase in the number of registered nurses (RNs) in recent years, most of the growth is accounted for by nurses over age fifty and foreign-born nurses. 10 Many hospitals are hiring temporary nurses through staffing agencies to address their shortages. This practice has raised concerns about the consistency and quality, as well as the cost, of care provided by temporary staff. The morale of nurses employed directly by the hospital also might suffer when they work alongside agency nurses who earn higher wages and enjoy more flexible scheduling. 11 These short-term fixes are not viable long-term solutions. Without immediate action, the nurse shortage will continue to worsen. By 2020, estimates suggest that the United States will have at least 400,000 fewer nurses than today, just when baby boomers will be in their seventies and eighties. 12 Instead of focusing on efforts to attract more new students into nursing schools, an admittedly important strategy, the RWJF is concentrating on the underlying issues that can make the hospital a more appealing and functional workplace. 13 The RWJF has a long but inconsistent history of supporting nurses, having invested more than $140 million in nursing programs since 1972, but not in a particularly targeted or strategic fashion. 14 Early initiatives included development and training programs for nurse practitioners, fellowships for nurse faculty, and a scholars program for clinical nurses. The RWJF has continued to support experienced nurse leaders through the Robert Wood Johnson Executive Nurse Fellows program, an advanced leadership and mentoring program for nurses in senior executive roles in health services, public health, and nursing education. The RWJF has, to date, invested $29.7 million in this program, which has supported more than 125 executive nurses since 1997, to give nursing and nurses a more influential role in transforming the U.S. health care system. In 2002 the foundation commissioned a report to help people better understand the current nurse shortage and suggest a possible response. 15 The report concluded that the shortage in 2002 was different from past shortages, which had resulted from mismatches between supply and demand. In contrast, the more recent shortage reflected nurses’ widespread dissatisfaction with their profession and greater competition from other career opportunities for women. The contents of this report helped shape the RWJF’s current work to improve the quality of care by focusing on the retention of experienced nurses. One of the foundation’s long-term goals is to see a dramatic increase in the proportion of new nurses who work in the same hospital for more than two years after graduation. The foundation’s objective is to help convert hospitals into places that are designed to promote healing, not just provide treatment; places where workers are engaged and supported in their jobs; and places where better work processes and culture increase institutional vitality and enhance patient care. Nurses spend much of their time searching for medications and doctors, hunting down needed equipment, and completing redundant paperwork. Better and more efficient systems of delivering nursing care must be developed. Transforming Care at the Bedside (TCAB), a collaborative project between the RWJF and the Institute for Healthcare Improvement (IHI), involves thirteen hospitals in a pilot program for medical/surgical nurses to identify and implement changes that will improve care in their units. Changes initiated through TCAB make it easier for nurses to spend more time with patients and less time on administrative tasks. In most cases, these innovations have been cost-neutral or have even saved money. In 2006, when the pilot phase of TCAB is complete, the foundation expects to develop a demonstration phase of the program that would reach a broader spectrum of U.S. hospitals. The TCAB hospital units have begun implementing a number of innovations that appear promising, but early results are still being evaluated. Several sites have initiated the use of rapid response teams, which enable a nurse to call on a team of clinicians to intervene when a patient’s condition appears to be deteriorating. This practice provides overt validation for nurses’ professional judgment and provides needed assistance for patients before they reach a more irrevocable point of crisis. Many of the TCAB projects are instituting small, simple changes to improve the work environment and the quality of patient care. For example, some units have established “peace and quiet time” for an hour during each nursing shift to promote a calming, healing environment for patients to rest. Several units have reduced nurses’ “hunting and gathering” time by moving supplies from a central location on the unit to patients’ rooms, ensuring that each room is stocked with the correct supplies for a particular patient and allowing nurses to spend more time providing direct patient care. Hospitals are also dangerous; patients are exposed to infection and injuries that could be prevented if hospitals had better designs. 16 An analysis of more than 600 studies, which was funded by the foundation and conducted by the Center for Health Design, demonstrated a direct link between hospital design and a wide variety of patient outcomes, patient and staff satisfaction, and staff efficiency. 17 The hospital sector is experiencing a major building boom: More than $200 billion is expected to be spent on new hospitals and nursing homes in the next decade. 18 Using the evidence about the benefits of physical design, we can ensure that future hospitals will be safer, quieter, and less stressful healing environments. Key characteristics of the ideal hospital unit include single-patient rooms, positive distractions such as windows and artwork, enough prominently placed hand-washing stations, and ceiling and floor surfaces that absorb noise rather than amplifying it. Another promising design intervention is the acuity-adaptable room, which features the equipment and functionality to allow patients to remain in the same room, even when their condition changes during their hospital stay. This capacity is particularly important, given the risk of medical errors and infections, as well as the resources and staff time required, when patients are transferred from one room to another. The foundation will continue to support research and dissemination efforts to inform architects, hospital executives and trustees, and state regulators about the growing evidence showing the necessity to design hospitals that support patients’ and caregivers’ needs. As hospitals invest in changes to their physical environment, they must also be mindful of the institutional work environment. An organization’s vitality, values, and culture profoundly affect its employees. Hospital nurses have difficult, demanding jobs; they need to feel inspired by their work and supported as professionals if optimal patient care is to be achieved. The RWJF is only beginning to explore the opportunities in this area and is learning from leaders who have initiated changes to improve their hospitals’ culture. To date, the foundation has commissioned a white paper on organizational culture that examines the characteristics of positive hospital culture. Early in 2006 the RWJF expects to fund several hospitals to produce reports or case studies that describe successful approaches to improving organizational culture. These might include fostering relationships between new nurses and more experienced mentors; using new models of communication to improve information exchange between nurses and physicians; and exploring opportunities for all hospital staff to feel valued and respected. Industries outside of health care might offer important learning opportunities to improve organizational culture; to initiate changes in hospital culture, the RWJF is interested in testing models used in other fields. For example, the airline industry has used a Crew Resource Management model to develop highly functional teams and foster a culture of trust in which staff at all levels feel empowered to communicate their opinions—and, more importantly, their concerns about safety or errors—without fear of blame or retribution. Adapting this approach to teamwork and communication could be valuable for nurses and other health care providers—and, ultimately, patients and families—in hospitals. Much research is still needed to explore, measure, and better define the relationship between nursing care and patient outcomes; to uncover why newly licensed nurses tend to leave a hospital after only a short time; and to identify viable strategies for addressing the shortage of nurse faculty. The RWJF is also interested in sharing relevant findings with a broad audience; one channel for doing so is the foundation-sponsored policy brief series, Charting Nursing’s Future, which highlights some of the key research and policy issues in the nursing field. 19 In November 2005 the RWJF launched its Interdisciplinary Nursing Quality Research Initiative, which will support teams of nurse and nonnurse scholars to gather evidence about the relationship between nursing and high-quality patient care. This initiative will complement the RWJF’s work with the National Quality Forum and others to identify patient outcomes that are sensitive to nursing care and set priorities for developing effective measures of the quality of that care. 20 The RWJF also is supporting researchers at New York University and the University of Buffalo to conduct a cohort study that will track newly licensed nurses over four years to learn more about their career paths and the factors that affect their work decisions. Another project explores what types of employer-based benefits might bolster nurse retention. 21 The foundation is also interested in learning more about nurses who continue to work in hospitals for many years and in identifying opportunities to increase retention of experienced nurses. The RWJF has supported a white paper, expected in spring 2006, to uncover what factors influence senior nurses’ decisions to continue working in a hospital and to identify promising practices from other fields, such as education, that have had success in retaining older and experienced workers. Finally, the RWJF will support an effort to incorporate information about quality improvement and ways to improve safety in nursing school curricula nationwide; this work will complement the training taking place in TCAB hospitals. The RWJF will continue its commitment to supporting leadership among nurses at all levels, from student nurses to hospital executives. The foundation recently established the Fellowship in Nursing Policy and Philanthropy, which enables a midcareer nurse leader to pursue projects jointly at the RWJF and Rutgers University’s Center for State Health Policy. The RWJF also is making a concerted effort to engage more nurses in its Health Policy Fellowships Program, designed to provide outstanding midcareer health professionals with a better understanding of and role in the health policy process. In December 2005 the RWJF and the Northwest Health Foundation, in Portland, Oregon, expected to jointly launch the Partners Investing in Nursing’s Future initiative, which will support local foundations’ efforts to address the most pressing nursing issues in their communities. The RWJF is not alone in its support for programs to address the nurse shortage and improve the delivery of nursing care. Public and private organizations across the country are investing in nursing at the local, state, and national levels. The list of initiatives described below is by no means comprehensive; rather, it is intended to illustrate the variety of strategies that different funders are supporting. Notably, the Gordon and Betty Moore Foundation in San Francisco has allocated substantial resources to address the nurse shortage in the Bay Area of California. In 2003 that foundation committed $110 million to its ten-year Betty Irene Moore Nursing Initiative, which is designed to improve the quality of nursing-related patient care in the area’s acute care hospitals. This initiative will support efforts to increase the number of nurses graduating from local nursing schools; retain experienced nurses in selected acute care hospitals; and identify promising strategies to recruit, train, and retain highly qualified nurses. Funded projects include fellowships for doctoral students at the School of Nursing, University of California, San Francisco (UCSF); the establishment of an evening associate degree in nursing program in partnership with California Pacific Medical Center, St. Luke’s Hospital, and City College of San Francisco; and research to measure patient outcomes related to nursing care. The California Endowment also has made a sizable investment in addressing the nurse shortage in California, through a $1.4 million grant to prepare foreign-trained nurses, physicians, and dentists for the licensure exams that allow them to practice in the state. The Jewish Healthcare Foundation (JHF) of Pittsburgh has made important investments to address the nurse shortage and improve the quality and safety of nursing care. It has supported a program that educates middle school and high school students about career opportunities in nursing; a fellowship to develop nursing students’ skills; and a summit to inform local hospitals about the American Nurses Credentialing Center’s Magnet Recognition Program. In 2005 the JHF launched a new Nurse Navigator Fellowship program that provides $10,000 grants to foster Pennsylvania nurses’ skills in data measurement and collection to improve the quality of patient care and to promote nurse leadership. Fostering leadership and scholarship are key components of many foundations’ initiatives to address the nurse shortage. The Palm Healthcare Foundation in West Palm Beach, Florida, has committed $2 million over ten years to its Nursing Education Initiative; the funder’s signature initiative is a community-based nurse preceptor program. Also, in partnership with the Christine E. Lynn College of Nursing at Florida Atlantic University, Palm Healthcare supports an institute to improve nurses’ leadership and clinical skills and support faculty development. The John A. Hartford Foundation, in New York City, which focuses on improving health care for older Americans, authorized more than $40 million over eight years to support geriatric nursing programs. A key initiative is a scholarship program that has supported more than 100 nurse scholars and fellows to conduct research in gerontological nursing. In 2003 the Northwest Health Foundation launched a five-year, $5 million initiative to reduce the nurse shortage in Oregon and southwest Washington State. These efforts focus on improving nursing education and increasing nursing faculty, retaining nurses in the work-place, and increasing racial and ethnic diversity in the nursing workforce. The W.K. Kellogg Foundation in Battle Creek, Michigan, also has invested in work to increase racial and ethnic diversity in nursing, primarily through a $2 million grant in support of the Leadership Enhancement and Development Project of the American Nurses’ Foundation. And finally, the Blue Cross Blue Shield of Michigan Foundation invested $500,000 over two years to support scholarships and research training for nursing students as well as other programs to attract and retain nurse faculty at Michigan colleges and universities. Federal agencies also have allocated funds to support adequate nurse staffing. In 2004 the Health Resources and Services Administration’s (HRSA’s) Division of Nursing received appropriations for nearly $142 million in support of nursing education, student scholarships, nurse retention, workforce diversity, and faculty development. Also in 2004 the Centers for Medicare and Medicaid Services (CMS) awarded more than $6 million in grants to sixteen hospitals for Patient Care Work Force Stabilization programs, designed to ensure adequate hospital staffing, address retention of experienced nurses, and secure competitive compensation for hospital employees. The CMS also is working to develop more stringent requirements for nursing homes to release public reports on their staff training, retention, and use of nonnurse staff to provide patient care. The Agency for Healthcare Research and Quality (AHRQ) committed an estimated $172 million to nursing issues in 2005. AHRQ supports health services research in areas such as patient safety, health care quality, and health IT. The agency also provides training grants, including dissertation grants, to nurse researchers and maintains databases that can be used for secondary analyses. In June 2005 U.S. Secretary of Labor Elaine Chao announced a $1.1 million federal grant to support a nurse training partnership in New York City between Pace University’s Lienhard School of Nursing and the Northern Metropolitan Hospital Association. Funds will be used to train new nursing instructors and mentors. At the state level, both Arizona and Utah have introduced legislation to address the nurse shortage. In Arizona, a five-year, $40 million program aims to double the number of nurse graduates in the state by the year 2010 by expanding the capacity of nursing education programs and funding additional faculty. In Utah, the state legislature and the state’s hospitals together have committed $3 million to increase the number of nursing school faculty. Nationwide, nearly 33,000 nursing school applications from qualified students were turned down in 2004, largely because of faculty shortages. 22 One of the most visible corporate supporters of nursing in the past several years has been Johnson and Johnson, which has invested more than $30 million in its Campaign for Nursing’s Future. Working with Johnson and Johnson and Grant-makers In Health, the RWJF plans to release a resource guide in 2006 to help local funders understand the national issues related to the nurse shortage and identify how efforts to improve the recruitment and retention of skilled nurses might be undertaken locally. T he nurse shortage today is more complex than shortages of the past, and the stakes are higher than ever as the population ages and contends with more chronic conditions. Ending the shortage will require efforts not only to recruit new nurses and address faculty shortages in schools of nursing but also to work with hospital administrators, nurse leaders, and nurses at the bedside to improve the work environment for nurses and with researchers to shed light on the many factors related to the problem and on promising solutions. Susan Hassmiller ( [email protected] ) is a senior program officer and the leader of the nursing team at the Robert Wood Johnson Foundation (RWJF). She is a fellow of the American Academy of Nursing. Maureen Cozine is a communications officer for the RWJF’s nursing team.
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Why was the shortage of nurses that occurred before Medicare different from subsequent shortages
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