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 second of a two-part Q&A, O'Neil discusses a framework for solutions to the nursing shortage.
You've discussed the current state of the nursing shortage and provided an analysis of the future. How are health care organizations responding to this growing problem?
There is a tremendous amount of activity in the health care industry to develop more than temporary “quick fixes” to the nursing shortage. The shortage continues to be a reality at many hospitals in the United States. In fact, the United States Bureau of Labor Statistics estimates that 1 million new nurses will be needed by 2020.
I've taken a look at what funders, government agencies, and leading health care organizations are doing to alleviate the national nursing shortage and found that responses tend to fall into one of four categories: scramble (nurse as commodity), improve (nurse as customer), reinvent (nurse as valued asset), and start over (nurse as professional partner). The responses in each category move from short-term to long-term, less complex to more complex.
Describe these four categories of response.
The solutions in the scramble category are simple and short term. While they may be very necessary in the present, they are inadequate in the long term. Scramble responses tend to consider nurses as a commodity and aim to increase the number of nurses. Some of these include educational recruitment, public relations campaigns and labor organizing. We have also seen solutions focused on increasing staff recruitment through signing bonuses, international recruitment, traveler or staffing companies, and education support or loan forgiveness.
Responses in the improve category are focused on improving the nursing profession because nurses are viewed as a customer. These are more middle-term strategies, such as engaging nurses through educational opportunities, increasing the number of nursing faculty to improve nurse preparation, improving recruitment and performance of underrepresented students, better integrating nursing education into nursing practice, and increasing nursing practice's support of education. We have seen efforts to improve the transition from education to practice through structured mentoring and “residency” programs. The improve stage also includes nursing-driven quality improvement initiatives, balanced with an externally driven demand for quality improvement from programs such as Magnet [the American Nurses Credentialing Center's Magnet Recognition Program®], JCAHO [the Joint Commission on Accreditation of Healthcare Organizations], and pay-for-performance incentives.
In the reinvent category, longer-term strategies are implemented and nurses are seen as a valued asset. In this category, the care delivery leader in the executive suite recognizes that the most important asset in achieving goals like improved patient safety, higher levels of consumer satisfaction, and more efficient use of resources is embedded in the nursing staff. The question becomes, “How do I release that power?” Examples include a radical integration between education and practice, including the integration of faculty and clinician, classroom and health care facility, and student and nursing professional; bold steps to reintegrate two- and four-year training resources, and moving beyond the old industrial model for labor organizing to one based on the service sector, an approach which recognizes and rewards quality, life-long professional development and individual effort.
Responses that start over are forward thinking out 15 to 20 years. These approaches recognize that there are certain dynamics of the health care system that are not sustainable, so it is best to start over with new assumptions. Some of these responses include reorganizing nurse practices around treatment of chronically ill people in home and community settings, incorporating the use of new technologies, and reframing the nursing shortage from a workforce problem to a jobs development opportunity.
Which responses have had the most impact?
Each category holds valuable responses and solutions, and smart leaders will have a balanced set of responses in all four categories. Scramble solves the immediate pain with “quick fix” recruitment or image campaigns. By necessity, scrambling will occupy 10 to 15 percent of leadership's focus.
There is a lot to improve, and hospital staffing efforts have yielded a return, as have efforts to change the work environment, making it less toxic.
Reinvent takes time and creativity, but if risks can be taken, then some of the new ideas—like regional training cooperatives deploying common simulation that builds into standardized nursing protocol—have great promise. Also, nursing leadership development from the front line to the executive suite has had a demonstrable impact. Balanced efforts split 70 percent of executive focus between these two.
Starting over is hard because it is so far out, but if the leadership can get 10 percent of the strategic imagination focused here, it can pay big dividends by informing the process to plan new facilities or taking a decade to recruit and train a new type of nursing staff, or building a deep partnership with payers to build and support programs of quality development.
What should be done by various organizations with a stake in alleviating the nursing shortage?
The health care community is coming together to find permanent solutions to this growing problem, and that collaboration is extremely important. Health care leaders, policy-makers and philanthropies are coming to the same table to take a critical look at the short- and long-term solutions outlined above, determine the gaps, and develop strategies to close those gaps and reduce the nursing shortage in this country. Yet, there are actions that the health care community can take:
- Create new models that recognize the critical role nurses play in the delivery of safe, high-quality patient care;
- Dedicate more dollars toward research, specifically around nursing's contribution to health care outcomes and patient satisfaction;
- Reinvent nursing education to address the needs and values of—and to appeal to—a new generation of nurses;
- Examine the work environment for nurses so that hospitals and other health care facilities are safer places for nurses to work and patients to receive care;
- Establish a national nursing workforce measurement and data collection system; and
- Create a clearinghouse of effective strategies to advance cultural change with the nursing profession.