Edward O'Neil, M.P.A., Ph.D., F.A.A.N., is the director of the Center for Health Professions at the University of California at San Francisco. The Center houses the Robert Wood Johnson Executive Nurse Fellows Program, an advanced leadership program for nurses in senior executive roles in health services, public health and nursing education who aspire to help lead and shape the U.S. health care system of the future. In the first of a two-part Q&A, O'Neil presents an overview of the current state of the nursing shortage.

What are the factors contributing to the current nursing shortage in the United States?

Three elements can explain the current status of nursing in the U.S.: the combination of a demographic perfect storm, the spiraling costs of health care, and an inability of the nursing education system to meet the demand for education.

There are several factors that are contributing to the perfect storm. The first is the aging of the baby boomer. Boomers are beginning to turn 60 this year, and they will drain health care resources as they age and develop chronic illness. This is not necessarily a sicker population; there are just many more aging Americans who naturally develop chronic conditions as they age. Nurses are aging alongside the baby boomers. In 1980, 40 percent of nurses were under the age of 35. By 2004, that number shrank to 16.6 percent, and nurses over the age of 54 represented 25.5 percent of all nurses. Not only are nurses older, but the pool of potential nurses has grown smaller, as birth rates have generally dwindled since the end of the baby boom that followed World War II. Finally, the pool from which to draw nurses is even smaller because fewer men and minorities choose nursing as a profession. In fact, in 2004, male R.N.s accounted for only 5.7 percent of all nurses.

At the same time that health care is experiencing the effects of this demographic perfect storm, U.S. health care costs are skyrocketing. Health care continues to be an enormous expenditure for the U.S., accounting for 16 percent of the total Gross Domestic Product (GDP). These out of control costs are forcing health care leaders to redistribute resources. Hospitals, where 60 to 65 percent of nurses practice, are experiencing the most cost cuts. Not only are the resources to support nurses harder to come by, but the acuity of the patient has increased. So, while admissions and length of stay are down, patients' problems are more complex and they are being served by fewer nurses. The hospital has become a pressure cooker environment.

Although the level of interest in nursing dropped between 1995 and 2000, the demand for nursing education has rebounded and now exceeds the capacity of nursing education to respond. The problem is a combination of lack of facilities, shortage of new faculties, and lack of clinical placements. The answers will be a combination of new appropriations and focus on these issues and new ways of addressing education, including simulation, online education, and education and delivery partnerships.

How immediate is the problem of the nursing shortage?

Although many consider the nursing shortage a past or present problem, the real shortage is in the immediate future as the majority of baby boomers reach mature ages, by 2020. Increased care-demands from boomers who are aging, coupled with a missing generation of new nurses, translates into a future gap in care that will be larger than what health care is currently experiencing.

Are we making any progress toward a solution to the nursing shortage?

The news is not all bad. The numbers of U.S. candidates taking R.N. exams has increased from 68,759 in 2001 to 99,089 in 2005. However, the shortfall will become more evident in the future as the current group of nurses ages along with the general population.

Additionally, there are more high-quality nurses entering the workforce. While some numbers of nurses are increasing, so is the quality of candidates. In fact, the National Council of State Boards of Nursing reports that pass rates for R.N. candidates have increased from 68.8 percent in 2000 to 87.3 percent in 2005.